Provider Demographics
NPI:1902079510
Name:MARSOLEK, PETER J
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MARSOLEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 BEASER AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3638
Mailing Address - Country:US
Mailing Address - Phone:715-682-0482
Mailing Address - Fax:715-682-4297
Practice Address - Street 1:2101 BEASER AVE
Practice Address - Street 2:STE 6
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3638
Practice Address - Country:US
Practice Address - Phone:715-682-0482
Practice Address - Fax:715-682-4297
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38451400Medicaid
WI5330570002Medicare NSC