Provider Demographics
NPI:1588350771
Name:BUDJAK, GINA (DC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BUDJAK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:PERCUOCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-532-7600
Mailing Address - Fax:
Practice Address - Street 1:N112W17975 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-2425
Practice Address - Country:US
Practice Address - Phone:563-271-8348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6068-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100238015Medicaid