Provider Demographics
NPI:1588777999
Name:DVORAK, BRIAN J (PT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:DVORAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2104
Mailing Address - Country:US
Mailing Address - Phone:920-356-1000
Mailing Address - Fax:920-356-0719
Practice Address - Street 1:118 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2104
Practice Address - Country:US
Practice Address - Phone:920-356-1000
Practice Address - Fax:920-356-0719
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40452200Medicaid
WI61270OtherDEAN HEALTH SYSTEMS
WI000381051Medicare PIN
WI000381043Medicare PIN