Provider Demographics
NPI:1699924100
Name:MAGGIOLINO, GIACOMO (MD)
Entity type:Individual
Prefix:DR
First Name:GIACOMO
Middle Name:
Last Name:MAGGIOLINO
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-683-5278
Mailing Address - Fax:920-686-9674
Practice Address - Street 1:8501 75TH ST STE J
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7602
Practice Address - Country:US
Practice Address - Phone:262-697-8030
Practice Address - Fax:262-697-6157
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53395-020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI53395-020OtherSTATE LICENSE
WIP00745558OtherRAILROAD MEDICARE
WI53395-020OtherSTATE LICENSE
WI1699924100Medicaid
WI382000017OtherMEDICARE
WIFM1111551OtherDEA
WIP00745558OtherRAILROAD MEDICARE