Provider Demographics
NPI:1629045232
Name:GUTTORMSEN, BRIAN NEIL (MD)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:NEIL
Last Name:GUTTORMSEN
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:PO BOX 88040
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53288-0040
Mailing Address - Country:US
Mailing Address - Phone:920-886-9380
Mailing Address - Fax:920-886-9381
Practice Address - Street 1:5045 W GRANDE MARKET DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8517
Practice Address - Country:US
Practice Address - Phone:920-886-9380
Practice Address - Fax:920-886-9381
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44932207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34686200Medicaid
WI0036Medicare PIN
I41486Medicare UPIN