Provider Demographics
NPI:1720057771
Name:JIONGCO, EDGARDO C (MD)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:C
Last Name:JIONGCO
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 1:8007 EXCELSIOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717
Mailing Address - Country:US
Mailing Address - Phone:608-829-5238
Mailing Address - Fax:608-833-6932
Practice Address - Street 1:601 HANDEYSIDE LANE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538
Practice Address - Country:US
Practice Address - Phone:920-563-5544
Practice Address - Fax:608-833-6932
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI205142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31094800Medicaid
WI31094800Medicaid