Provider Demographics
NPI:1124028527
Name:MUDRY, BRIAN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MUDRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 EASY ST
Mailing Address - Street 2:SUITE 127
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-3129
Mailing Address - Country:US
Mailing Address - Phone:724-430-8755
Mailing Address - Fax:724-434-1659
Practice Address - Street 1:2175 MCCLELLANDTOWN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MASONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15461-2593
Practice Address - Country:US
Practice Address - Phone:724-583-1401
Practice Address - Fax:724-583-8550
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010287L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1742037OtherHIGHMARK
PA1012694790001Medicaid
PA090450Medicare ID - Type Unspecified
PAH80562Medicare UPIN