Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 036117547 | IL |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 036117547 | IL |
NPI | 1235177023 |
---|---|
Provider Name | Brett W Wolters |
First Address | Springfield, IL 62703-2403 |
Second Address | Springfield, IL 62702-3719 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2006 |
Last Update Date | 19/05/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036117547 | (05) | IL |