Healthcare Provider Details

I. General information

NPI: 1912136656
Provider Name (Legal Business Name): BRIAN JOHN OBROCHTA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 UNION AVE
SHEBOYGAN WI
53081-8426
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-828-2700
  • Fax:
Mailing address:
  • Phone: 920-828-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101018151
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number62405
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: