Basic Information
| Provider Information | |||||||||
| NPI: | 1124065537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VUKICH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5715 W OLD SHAKOPEE RD # 150 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554373107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082822000 | ||||||||
| FaxNumber: | 6082822172 | ||||||||
| Practice Location | |||||||||
| Address1: | 10425 W NORTH AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148776414 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 30091-020 | WI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 2128 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 31478100 | 05 | WI | MEDICAID |