Provider Demographics
NPI:1760055578
Name:UTZIG, JAMISON CLYDE DAVID (MD)
Entity type:Individual
Prefix:
First Name:JAMISON
Middle Name:CLYDE DAVID
Last Name:UTZIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAMISON
Other - Middle Name:CLYDE DAVID
Other - Last Name:UTZIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:1550 HOBBS DR
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2027
Practice Address - Country:US
Practice Address - Phone:262-740-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81756-20207Q00000X
WI8828-851390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100255255Medicaid