Provider Demographics
NPI:1538768957
Name:DISABATO, JOHN MICHAEL JR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:DISABATO
Suffix:JR
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 1:551 LEAH LN APT 3F
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7194
Mailing Address - Country:US
Mailing Address - Phone:815-341-6243
Mailing Address - Fax:
Practice Address - Street 1:201 S EDWARDS BLVD
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4507
Practice Address - Country:US
Practice Address - Phone:262-248-3391
Practice Address - Fax:262-248-3421
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12399-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist