Provider Demographics
NPI:1871855882
Name:GOMMERMANN, JOHN ALOIS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALOIS
Last Name:GOMMERMANN
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:N2753 JOHNS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-7966
Mailing Address - Country:US
Mailing Address - Phone:920-787-4585
Mailing Address - Fax:
Practice Address - Street 1:N2753 JOHNS LAKE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-7966
Practice Address - Country:US
Practice Address - Phone:920-787-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22373-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology