Healthcare Provider Details

I. General information

NPI: 1841344272
Provider Name (Legal Business Name): SCOTT ALLEN HOFTIEZER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W LINCOLN ST DCI HEALTH SERVICE UNIT
WAUPUN WI
53963-1949
US

IV. Provider business mailing address

1 W LINCOLN ST DCI HEALTH SERVICE UNIT
WAUPUN WI
53963-1949
US

V. Phone/Fax

Practice location:
  • Phone: 920-324-6482
  • Fax: 920-324-6288
Mailing address:
  • Phone: 920-324-6482
  • Fax: 920-324-6288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26625
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: