Healthcare Provider Details

I. General information

NPI: 1215167051
Provider Name (Legal Business Name): BRYAN T HOTUJEC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-2569
US

IV. Provider business mailing address

3960 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-2569
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-9236
  • Fax: 763-684-6006
Mailing address:
  • Phone: 763-236-9236
  • Fax: 763-236-9250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number55026-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: