Provider Demographics
NPI:1023021151
Name:O'SHAUGHNESSY, BRIAN E (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:O'SHAUGHNESSY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 W DALE ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1925
Mailing Address - Country:US
Mailing Address - Phone:319-235-5060
Mailing Address - Fax:319-235-5061
Practice Address - Street 1:152 W DALE ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1925
Practice Address - Country:US
Practice Address - Phone:319-235-5060
Practice Address - Fax:319-235-5061
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0667092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066709Medicaid
IL036066709Medicaid
ILL53566Medicare ID - Type Unspecified
IL0727500001Medicare NSC
ILL53561Medicare UPIN
C37502Medicare UPIN