Provider Demographics
NPI:1780733477
Name:KOSKINEN, GERALD W (OD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:W
Last Name:KOSKINEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3278 W MAIN ST
Mailing Address - Street 2:P O BOX 165
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-0165
Mailing Address - Country:US
Mailing Address - Phone:262-642-9719
Mailing Address - Fax:262-642-2228
Practice Address - Street 1:3278 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-0165
Practice Address - Country:US
Practice Address - Phone:262-642-9719
Practice Address - Fax:262-642-2228
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2184152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38574600Medicaid
WI410030984Medicare PIN
WIT62475Medicare UPIN
WI38574600Medicaid