Provider Demographics
NPI:1346224573
Name:MEDEIROS, BRIAN L (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:MEDEIROS
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 1:1030 PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-5923
Mailing Address - Country:US
Mailing Address - Phone:508-679-6833
Mailing Address - Fax:508-678-2200
Practice Address - Street 1:1030 PRESIDENT AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5923
Practice Address - Country:US
Practice Address - Phone:508-679-6833
Practice Address - Fax:508-678-2200
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151376208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3156851Medicaid