Provider Demographics
NPI:1528118635
Name:MUTSCH, ROY W (DC)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:W
Last Name:MUTSCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W71N918 HARRISON CT
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-3234
Mailing Address - Country:US
Mailing Address - Phone:262-375-4776
Mailing Address - Fax:
Practice Address - Street 1:4680 W BRADLEY RD
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-3764
Practice Address - Country:US
Practice Address - Phone:414-355-7690
Practice Address - Fax:414-355-7672
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1651111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38908100Medicaid
WI38908100Medicaid