Provider Demographics
NPI:1447236492
Name:HUCKSTORF, BRIAN L (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:HUCKSTORF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-2475
Practice Address - Fax:262-928-5697
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI44448-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV34207500Medicaid
WIH67933Medicare UPIN
WI0053Medicare ID - Type Unspecified