Provider Demographics
NPI:1316152598
Name:CUSTODIO, DON L (MD)
Entity type:Individual
Prefix:
First Name:DON
Middle Name:L
Last Name:CUSTODIO
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 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:4100 STATE HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482-8410
Practice Address - Country:US
Practice Address - Phone:715-343-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085609207P00000X
WI3088207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00631547Medicare PIN
MIM90900051Medicare PIN
MIC96038065Medicare PIN