Provider Demographics
NPI:1295735348
Name:INTROCASO, JOSEPH H (MD, DMD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:H
Last Name:INTROCASO
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N COMMERCIAL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2657
Mailing Address - Country:US
Mailing Address - Phone:920-722-1840
Mailing Address - Fax:920-722-7454
Practice Address - Street 1:333 N COMMERCIAL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2657
Practice Address - Country:US
Practice Address - Phone:920-722-1840
Practice Address - Fax:920-722-7454
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360871842085R0202X, 2085R0202X
WI539922085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202926OtherGROUP PTAN
IL036087184Medicaid
IL212545OtherGROUP PTAN
IL212545OtherGROUP PTAN
IL202926OtherGROUP PTAN
IL212545002Medicare PIN