Provider Demographics
NPI:1679580070
Name:ROSCULET, JOHN P (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:ROSCULET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 THEDA CLARK PLAZA
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956
Mailing Address - Country:US
Mailing Address - Phone:920-751-8666
Mailing Address - Fax:920-751-8676
Practice Address - Street 1:200 THEDA CLARK PLAZA
Practice Address - Street 2:SUITE 110
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-751-8666
Practice Address - Fax:920-751-8676
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34273020207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31922100Medicaid
WI000171495Medicare ID - Type UnspecifiedWINNEBAGO CO
WI000107670Medicare ID - Type UnspecifiedBROWN COUNTY GROUP #
F27053Medicare UPIN