Provider Demographics
NPI:1952393738
Name:PIETROCARLO, THOMAS ANTHONY (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ANTHONY
Last Name:PIETROCARLO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430C N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1605
Mailing Address - Country:US
Mailing Address - Phone:262-542-3779
Mailing Address - Fax:262-542-3954
Practice Address - Street 1:2430C N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1605
Practice Address - Country:US
Practice Address - Phone:262-542-3779
Practice Address - Fax:262-542-3954
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI408213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43210100Medicaid
WIT63005Medicare UPIN
WI43210100Medicaid
WI0220260001Medicare NSC
WICE9921Medicare PIN