Provider Demographics
NPI:1154367811
Name:DUCLOUX, HAROLD PENNINGTON (MD)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:PENNINGTON
Last Name:DUCLOUX
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 1:10400 W NORTH AVVE SUITE 490
Mailing Address - Street 2:AMG MID-MARKET URGENT CARE GROUP
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-5701
Mailing Address - Country:US
Mailing Address - Phone:414-479-3758
Mailing Address - Fax:414-479-7254
Practice Address - Street 1:10400 W NORTH AVVE SUITE 490
Practice Address - Street 2:AMG MID-MARKET URGENT CARE GROUP
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-5701
Practice Address - Country:US
Practice Address - Phone:414-479-3758
Practice Address - Fax:414-479-7254
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA044708207Q00000X
WI51478-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G87811Medicare UPIN