Provider Demographics
NPI:1821170986
Name:VAN HOOZEN, BRIAN L (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:VAN HOOZEN
Suffix:
Gender:M
Credentials:DO
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 96
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-0096
Mailing Address - Country:US
Mailing Address - Phone:920-982-7900
Mailing Address - Fax:920-982-7995
Practice Address - Street 1:1505 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2187
Practice Address - Country:US
Practice Address - Phone:920-982-7900
Practice Address - Fax:920-982-7995
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32699207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11014110Medicaid
WI390848401050OtherCMH ANTHEM
WI30054700Medicaid
WIB44275Medicare UPIN
WI30054700Medicaid
WI521310Medicare Oscar/Certification
WI390848401050OtherCMH ANTHEM