Provider Demographics
NPI:1780752329
Name:WILLIQUETTE, JEFFREY J (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:WILLIQUETTE
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 1:232 S COURTNEY ST
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-3319
Mailing Address - Country:US
Mailing Address - Phone:715-365-1515
Mailing Address - Fax:715-365-1518
Practice Address - Street 1:232 S COURTNEY ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3319
Practice Address - Country:US
Practice Address - Phone:715-365-1515
Practice Address - Fax:715-365-1518
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38518200Medicaid
WI38518200Medicaid