Provider Demographics
NPI:1851383525
Name:PUSATERI, GARY M (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:M
Last Name:PUSATERI
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:E23570 POW WOW TRAIL
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969
Mailing Address - Country:US
Mailing Address - Phone:906-358-4588
Mailing Address - Fax:906-358-4588
Practice Address - Street 1:3144 VANZILE RD
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8149
Practice Address - Country:US
Practice Address - Phone:715-478-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29938-020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31543400Medicaid
WI000923035Medicare ID - Type Unspecified
F16365Medicare UPIN