Basic Information
| Provider Information | |||||||||
| NPI: | 1841722451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOVINSKI | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 TUTTLE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083562020 | ||||||||
| FaxNumber: | 6083557055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 TUTTLE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539131501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083562020 | ||||||||
| FaxNumber: | 6083557055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2017 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207W00000X | 74760-20 | WI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1841722451 | 05 | WI | MEDICAID |