Provider Demographics
NPI:1912304361
Name:ZAMZOW, BRIAN M
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:ZAMZOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N112W17975 MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-2425
Mailing Address - Country:US
Mailing Address - Phone:262-532-7680
Mailing Address - Fax:
Practice Address - Street 1:N112W17975 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-2425
Practice Address - Country:US
Practice Address - Phone:262-532-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5375225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100041622Medicaid