Provider Demographics
NPI:1760490262
Name:PELZ, THOMAS G (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:PELZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-6217
Mailing Address - Fax:608-375-5463
Practice Address - Street 1:200 W BLUFF ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1601
Practice Address - Country:US
Practice Address - Phone:608-375-2424
Practice Address - Fax:608-375-6285
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25166207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30019400Medicaid
WI000524160Medicare PIN
WI110048356Medicare PIN
B85142Medicare UPIN
WI003200486Medicare PIN