Provider Demographics
NPI:1841344272
Name:HOFTIEZER, SCOTT ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLEN
Last Name:HOFTIEZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 W LINCOLN ST
Mailing Address - Street 2:DCI HEALTH SERVICE UNIT
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1949
Mailing Address - Country:US
Mailing Address - Phone:920-324-6482
Mailing Address - Fax:920-324-6288
Practice Address - Street 1:1 W LINCOLN ST
Practice Address - Street 2:DCI HEALTH SERVICE UNIT
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1949
Practice Address - Country:US
Practice Address - Phone:920-324-6482
Practice Address - Fax:920-324-6288
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI26625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30765600Medicaid
WI30765600Medicaid