Provider Demographics
NPI:1538152962
Name:BACCUS, DONALD J (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:BACCUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-754-8000
Mailing Address - Fax:262-754-8008
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-754-8000
Practice Address - Fax:262-754-8008
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI21134207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30313100Medicaid
WI32666500Medicaid
WI30313100Medicaid
WI32666500Medicaid