Provider Demographics
NPI:1710910708
Name:GONIU, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GONIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10609 N RIVERLAKE CT
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-4865
Mailing Address - Country:US
Mailing Address - Phone:414-531-6048
Mailing Address - Fax:262-643-4791
Practice Address - Street 1:11430 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3414
Practice Address - Country:US
Practice Address - Phone:262-518-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30475300Medicaid
WI30475300Medicaid