Basic Information
| Provider Information | |||||||||
| NPI: | 1639139744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RINCON | ||||||||
| FirstName: | JAVIER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1440 | ||||||||
| Address2: | ATTN: CLINIC CREDENTIALING | ||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549821440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 S 70TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532143147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147736600 | ||||||||
| FaxNumber: | 4147736656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 09/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 29828 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31471200 | 05 | WI | MEDICAID |