Healthcare Provider Details

I. General information

NPI: 1760055578
Provider Name (Legal Business Name): JAMISON CLYDE DAVID UTZIG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAMISON CLYDE DAVID UTZIG MD

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 HOBBS DR
DELAVAN WI
53115-2027
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-740-4200
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number8828-851
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81756-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: