Provider Demographics
NPI:1588695985
Name:GOLLUP, HOWARD J (MD)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:J
Last Name:GOLLUP
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 1:3003 W GOOD HOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:N112 W17975 MEQUON ROAD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53022
Practice Address - Country:US
Practice Address - Phone:262-532-7600
Practice Address - Fax:262-532-7602
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24163208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30413900Medicaid
WI30413900Medicaid
WI019940500Medicare PIN
WI462364730Medicare PIN