Provider Demographics
NPI:1295739225
Name:PRECIADO-RIESTRA, JUAN SEBASTIAN (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:SEBASTIAN
Last Name:PRECIADO-RIESTRA
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 1:933 BUFFALO RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-8192
Mailing Address - Country:US
Mailing Address - Phone:715-252-2899
Mailing Address - Fax:
Practice Address - Street 1:400 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6922
Practice Address - Country:US
Practice Address - Phone:920-787-4737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46438-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI521823OtherMEDICARE PART A - CLINIC
WI34313600Medicaid
WI46438OtherWI STATE LIC
WI521824OtherMEDICARE A MOBIL UNIT
WI521824OtherMEDICARE A MOBIL UNIT
WI34313600Medicaid