Provider Demographics
NPI:1053359612
Name:SALISBURY, JOHN E (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:SALISBURY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-1856
Mailing Address - Country:US
Mailing Address - Phone:920-788-4162
Mailing Address - Fax:920-788-6134
Practice Address - Street 1:607 WILSON ST
Practice Address - Street 2:
Practice Address - City:LITTLE CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54140-1856
Practice Address - Country:US
Practice Address - Phone:920-788-4162
Practice Address - Fax:920-788-6134
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38518000Medicaid
WIT63185Medicare UPIN
WI87024Medicare ID - Type Unspecified