Provider Demographics
NPI:1780663377
Name:ZASTROW, BRENT E (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:E
Last Name:ZASTROW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2646
Mailing Address - Country:US
Mailing Address - Phone:715-675-2321
Mailing Address - Fax:715-675-6530
Practice Address - Street 1:1445 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2646
Practice Address - Country:US
Practice Address - Phone:715-675-2321
Practice Address - Fax:715-675-6530
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1033-25213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1209098Medicaid
IAI9454Medicare ID - Type Unspecified
IA1209098Medicaid