Healthcare Provider Details

I. General information

NPI: 1255405338
Provider Name (Legal Business Name): BRYAN DAVID NETOLICKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 1ST AVE NE
CEDAR RAPIDS IA
52402-5433
US

IV. Provider business mailing address

PO BOX 1408
CEDAR RAPIDS IA
52406-1408
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-3993
  • Fax: 319-364-0116
Mailing address:
  • Phone: 319-365-3993
  • Fax: 319-364-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36197
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0473249
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: