Provider Demographics
NPI:1184689861
Name:DEPREST, BRIAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:DEPREST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4420 DIXIE HWY
Practice Address - Street 2:STE. 114
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2986
Practice Address - Country:US
Practice Address - Phone:502-449-6464
Practice Address - Fax:502-449-6465
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1049449OtherPASSPORT / NMA
000052155POtherHUMANA / NMA
000000350656OtherANTHEM / NMA
009856OtherSIHO / NMA
KYP00176786OtherRAILROAD MEDICARE
1193589OtherCHA / NMA
2432515000OtherPASSPORT ADVANTAGE / NMA
KY64320781Medicaid
1223284004OtherCIGNA / NMA
1193589OtherCHA / NMA
KYP00176786OtherRAILROAD MEDICARE