Provider Demographics
NPI:1033268545
Name:STUTZMAN, BRIAN WAYNE (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WAYNE
Last Name:STUTZMAN
Suffix:
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 1:1580 W 4TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2182
Mailing Address - Country:US
Mailing Address - Phone:208-888-9292
Mailing Address - Fax:208-888-3231
Practice Address - Street 1:1580 W 4TH ST STE 103
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2182
Practice Address - Country:US
Practice Address - Phone:208-888-9292
Practice Address - Fax:208-888-3231
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-708111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC708-5OtherBLUE CROSS
ID000010029531OtherREGENCE BLUE SHIELD
1673027Medicare UPIN