Provider Demographics
NPI:1750374096
Name:AVERY, JAMES A (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:AVERY
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 1:210 WISCONSIN AMERICAN DR
Mailing Address - Street 2:SUITE #265
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-2999
Mailing Address - Country:US
Mailing Address - Phone:920-907-7400
Mailing Address - Fax:920-907-7401
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:SUITE #265
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2999
Practice Address - Country:US
Practice Address - Phone:920-907-7400
Practice Address - Fax:920-907-7401
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24651-020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30463800Medicaid
WI30463800Medicaid
22235Medicare ID - Type Unspecified