Provider Demographics
NPI:1417964180
Name:BRINKMAN, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:BRINKMAN
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 1:3810 NORTHDALE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1871
Mailing Address - Country:US
Mailing Address - Phone:813-961-1331
Mailing Address - Fax:888-850-8316
Practice Address - Street 1:1101 31ST ST STE 170
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5581
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:888-812-8191
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38409208600000X
IL036049777208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64077696Medicaid
KY1964301Medicare ID - Type Unspecified
KY64077696Medicaid