Provider Demographics
NPI:1407957491
Name:BRUTVAN, FERDINAND M (MD)
Entity Type:Individual
Prefix:
First Name:FERDINAND
Middle Name:M
Last Name:BRUTVAN
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 1:1925 E IRON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2315
Mailing Address - Country:US
Mailing Address - Phone:414-481-6331
Mailing Address - Fax:
Practice Address - Street 1:1925 E IRON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-2315
Practice Address - Country:US
Practice Address - Phone:414-481-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI233992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30810200Medicaid
WI30810200Medicaid