Provider Demographics
NPI:1982650818
Name:IERULLI, VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:IERULLI
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 1:2251 N SHORE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-8360
Mailing Address - Country:US
Mailing Address - Phone:715-361-4700
Mailing Address - Fax:
Practice Address - Street 1:401 W MOHAWK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2218
Practice Address - Country:US
Practice Address - Phone:715-453-7200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43505900Medicaid
WI43505900Medicaid