Provider Demographics
NPI:1760427207
Name:FORMOLO, BRIAN E (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:FORMOLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 W RYAN RD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8233
Mailing Address - Country:US
Mailing Address - Phone:414-761-5777
Mailing Address - Fax:414-761-7915
Practice Address - Street 1:W180S6947 MUSKEGO DR
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-8532
Practice Address - Country:US
Practice Address - Phone:414-774-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3364111N00000X
FLCH12750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000035191Medicare PIN
WIU68240Medicare UPIN