Provider Demographics
NPI:1487606935
Name:LODICO, JOHN JR (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LODICO
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3958
Mailing Address - Country:US
Mailing Address - Phone:715-848-2526
Mailing Address - Fax:715-848-2225
Practice Address - Street 1:215 N BLACK RIVER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1529
Practice Address - Country:US
Practice Address - Phone:608-269-4511
Practice Address - Fax:608-269-8511
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2290-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38841100Medicaid
WI00235552Medicare ID - Type Unspecified
WI38841100Medicaid