Basic Information
| Provider Information | |||||||||
| NPI: | 1164426763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTEUCCI | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8153 S 27TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531329549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147610981 | ||||||||
| FaxNumber: | 4147611614 | ||||||||
| Practice Location | |||||||||
| Address1: | 8153 S 27TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531329549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147610981 | ||||||||
| FaxNumber: | 4147611614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 05/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 881025 | WI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 016005168 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 43237400 | 05 | WI | MEDICAID |