Provider Demographics
NPI:1760417430
Name:GUCCIARDI, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:GUCCIARDI
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 1:1185 CORPORATE CENTER DR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4887
Mailing Address - Country:US
Mailing Address - Phone:262-928-8400
Mailing Address - Fax:
Practice Address - Street 1:1185 CORPORATE CENTER DR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4887
Practice Address - Country:US
Practice Address - Phone:262-928-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31474600Medicaid
WIP00462701OtherRR MEDICARE
683750620Medicare PIN
WI73500-0098Medicare ID - Type Unspecified
WIP00462701OtherRR MEDICARE
WI31474600Medicaid
WI01994-0108Medicare PIN
WI46236-0108Medicare PIN