Provider Demographics
NPI:1932284296
Name:ELDRIDGE, EUGENE JOHN (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:JOHN
Last Name:ELDRIDGE
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 1:1400 75TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1544
Mailing Address - Country:US
Mailing Address - Phone:262-652-9500
Mailing Address - Fax:262-652-0760
Practice Address - Street 1:1400 75TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1544
Practice Address - Country:US
Practice Address - Phone:262-652-9500
Practice Address - Fax:262-652-0760
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25921207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31384000Medicaid
WID16353Medicare UPIN