1710971718 NPI number — RICHARD J GAUTHIER MD

Table of content: RICHARD J GAUTHIER MD (NPI 1710971718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710971718 NPI number — RICHARD J GAUTHIER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAUTHIER
Provider First Name:
RICHARD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710971718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 E DIVISION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54935-4560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-926-8343
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 PARKSIDE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIPON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54971-8508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-745-3520
Provider Business Practice Location Address Fax Number:
920-745-7932
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  26968 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30726500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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