Provider Demographics
NPI:1295832012
Name:BROTZMAN, WAYNE J JR (DO)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:J
Last Name:BROTZMAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WIND GAP
Mailing Address - State:PA
Mailing Address - Zip Code:18091-1628
Mailing Address - Country:US
Mailing Address - Phone:610-863-3019
Mailing Address - Fax:610-863-6732
Practice Address - Street 1:826 S BROADWAY
Practice Address - Street 2:
Practice Address - City:WIND GAP
Practice Address - State:PA
Practice Address - Zip Code:18091-1628
Practice Address - Country:US
Practice Address - Phone:610-863-3019
Practice Address - Fax:610-863-6732
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007427L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF09018Medicare UPIN
PA122737Medicare PIN