Provider Demographics
NPI:1164512612
Name:BRIAN T PRZYSTAWSKI, DPM, PCS
Entity Type:Organization
Organization Name:BRIAN T PRZYSTAWSKI, DPM, PCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PRZYSTAWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-895-3840
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-0708
Mailing Address - Country:US
Mailing Address - Phone:502-454-4187
Mailing Address - Fax:502-454-4235
Practice Address - Street 1:4119 BROWNS LANE
Practice Address - Street 2:BLD#2
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220
Practice Address - Country:US
Practice Address - Phone:502-895-3840
Practice Address - Fax:502-897-3642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80900202Medicaid
KY50003493Medicaid
KY80900202Medicaid
KY=========OtherHUMANA
=========OtherTRICARE
KY=========OtherANTHEM KY
9209Medicare PIN