Eddie Kiyoshi Brotkowski, D.D.S., M.D.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

1001767 Issued in WI

Practice address

464 S Hickory St Ste a
Fond Du Lac, WI 54935-5531

Phone

(920) 923-0111

Fax

(920) 923-0366

NPI assigned

Jun 2, 2011

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Mar 12, 2020 through Mar 12, 2028

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1306972800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1557100800000",
    "number": "1003100470",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2425 W KELLOGG AVE",
            "city": "WEST PEORIA",
            "state": "IL",
            "postal_code": "616045011",
            "telephone_number": "847-612-3407"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "464 S HICKORY ST STE A",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549355531",
            "telephone_number": "920-923-0111",
            "fax_number": "920-923-0366"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BROTKOWSKI",
        "first_name": "EDDIE",
        "middle_name": "KIYOSHI",
        "name_prefix": "Dr.",
        "credential": "D.D.S., M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-06-02",
        "last_updated": "2019-05-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "WI",
            "license": "1001767",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Rachael Brochtrup, PT
• Brooke N Brock
• Brookdale Senior Living Communities, Inc.
• Brooke Industries, Inc.
• Molly Marie Brooks, COTA
• Joline Brotzman, MS, RN, PMHCNS-BC
• Lisa Diane Brown, LCSW
• Lisette C Brown, PA C
• Pamela G Brown, OD
• Pierce Brown

• Oral and Maxillofacial Surgery (Dentist) in Fond Du Lac, WI
• Providers in Fond Du Lac, WI by specialty
• Oral and Maxillofacial Surgery (Dentist) in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.