Provider Demographics
NPI:1295784544
Name:HODULIK, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HODULIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1800 LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9108
Practice Address - Country:US
Practice Address - Phone:920-983-3220
Practice Address - Fax:920-983-3226
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI30409-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30409-20OtherWISCONSIN LICENSE
WIK400255865Medicare Oscar/Certification
WIK400181287Medicare Oscar/Certification
ORRODUM01WESMedicare PIN
ORE93247Medicare UPIN