Provider Demographics
NPI:1023050994
Name:ANDERSON, BRIAN L (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:ANDERSON
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 1:420 S KOELLER ST
Mailing Address - Street 2:STE 345
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-5593
Mailing Address - Country:US
Mailing Address - Phone:920-235-7373
Mailing Address - Fax:920-235-7713
Practice Address - Street 1:420 S KOELLER ST
Practice Address - Street 2:STE 345
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-5593
Practice Address - Country:US
Practice Address - Phone:920-235-7373
Practice Address - Fax:920-235-7713
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2355012111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38842700Medicaid
WIT65203Medicare UPIN