Healthcare Provider Details

I. General information

NPI: 1134125842
Provider Name (Legal Business Name): JOSEPH PUCCINELLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 11/16/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7545 N PORT WASHINGTON RD
GLENDALE WI
53217-3422
US

IV. Provider business mailing address

7545 N PORT WASHINGTON RD
GLENDALE WI
53217-3422
US

V. Phone/Fax

Practice location:
  • Phone: 414-351-3500
  • Fax: 414-351-9063
Mailing address:
  • Phone: 414-351-3500
  • Fax: 414-351-9063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number33107
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: