Provider Demographics
NPI:1093975500
Name:WALCOTT, BRIAN P (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:WALCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 76TH ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1984
Mailing Address - Country:US
Mailing Address - Phone:262-671-7710
Mailing Address - Fax:
Practice Address - Street 1:9555 76TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1984
Practice Address - Country:US
Practice Address - Phone:262-671-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.149400207T00000X
MA256503207T00000X
CAA136268207T00000X
WAMD60795316207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036149400OtherSTATE LICENSE
CAA136268OtherSTATE LICENSE