Provider Demographics
NPI:1003981994
Name:BOZELKA, BRIAN E (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:BOZELKA
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:164 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2728
Mailing Address - Country:US
Mailing Address - Phone:715-732-4181
Mailing Address - Fax:715-732-1348
Practice Address - Street 1:1400 UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-0046
Practice Address - Country:US
Practice Address - Phone:715-732-4181
Practice Address - Fax:715-732-1348
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35480020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32039400Medicaid
F82117Medicare UPIN
WI40106Medicare PIN