Healthcare Provider Details

I. General information

NPI: 1851383525
Provider Name (Legal Business Name): GARY M PUSATERI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3144 VANZILE RD
CRANDON WI
54520-8149
US

IV. Provider business mailing address

E23570 POW WOW TRAIL
WATERSMEET MI
49969
US

V. Phone/Fax

Practice location:
  • Phone: 715-478-5180
  • Fax:
Mailing address:
  • Phone: 906-358-4588
  • Fax: 906-358-4588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number29938-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: