Provider Demographics
NPI:1710971718
Name:GAUTHIER, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:GAUTHIER
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8343
Mailing Address - Fax:
Practice Address - Street 1:835 PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-8508
Practice Address - Country:US
Practice Address - Phone:920-745-3520
Practice Address - Fax:920-745-7932
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30726500Medicaid
WI021271018Medicare ID - Type Unspecified
WI30726500Medicaid