Provider Demographics
NPI:1588779441
Name:KINTZINGER, THOMAS LEE (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
Last Name:KINTZINGER
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:PO BOX 67
Mailing Address - Street 2:12550W MORELAND ROAD
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-0067
Mailing Address - Country:US
Mailing Address - Phone:715-462-3770
Mailing Address - Fax:
Practice Address - Street 1:12550 W MORELAND RD # 67
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-4525
Practice Address - Country:US
Practice Address - Phone:715-462-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25319-020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31468500Medicaid
B54147Medicare UPIN