Provider Demographics
NPI:1942388434
Name:OBUDZINSKI, JOHN ADAM (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ADAM
Last Name:OBUDZINSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:ADAM
Other - Last Name:OBUDZINSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100-15TH AVE.
Mailing Address - Street 2:STE 180
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-768-5430
Mailing Address - Fax:414-762-4225
Practice Address - Street 1:2424-S. 90TH ST.
Practice Address - Street 2:STE 214
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8777
Practice Address - Fax:414-328-8777
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006817207R00000X
WI21407-021207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
02120-0083Medicare PIN