Provider Demographics
NPI:1447220116
Name:FORD, BRIAN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROBERT
Last Name:FORD
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 1:2700 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1158
Mailing Address - Country:US
Mailing Address - Phone:712-336-2410
Mailing Address - Fax:712-336-3241
Practice Address - Street 1:2700 23RD ST
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1158
Practice Address - Country:US
Practice Address - Phone:712-336-2410
Practice Address - Fax:712-336-3241
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21046207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2177063Medicaid
IA2177063Medicaid