Provider Demographics
NPI:1275064792
Name:OVERHOLT, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:OVERHOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-3522
Mailing Address - Country:US
Mailing Address - Phone:414-649-6000
Mailing Address - Fax:
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI723362084A2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100095429Medicaid