Provider Demographics
NPI:1700830536
Name:THEUNE, GERALD O (OD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:O
Last Name:THEUNE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 N TRATT ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1212
Mailing Address - Country:US
Mailing Address - Phone:262-473-4514
Mailing Address - Fax:262-473-3161
Practice Address - Street 1:128 N TRATT ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1212
Practice Address - Country:US
Practice Address - Phone:262-473-4514
Practice Address - Fax:262-473-3161
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1557-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700830536Medicaid
WIP01423152Medicare PIN
WIK400177206Medicare PIN
WI38565100Medicaid
WI000547795Medicare PIN
WITHEUNGEROtherMERCYCARE
WI410048529Medicare PIN