Provider Demographics
NPI:1679569867
Name:MILITOLLO, JOSEPH M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:MILITOLLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:130 WARREN ST
Mailing Address - Street 2:STE 218
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3062
Mailing Address - Country:US
Mailing Address - Phone:920-887-0379
Mailing Address - Fax:920-887-0382
Practice Address - Street 1:130 WARREN ST
Practice Address - Street 2:STE 218
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3062
Practice Address - Country:US
Practice Address - Phone:920-887-0379
Practice Address - Fax:920-887-0382
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI17252208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31057600Medicaid
WI31057600Medicaid