Provider Demographics
NPI:1467527655
Name:OBRIEN, JOHN GERARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GERARD
Last Name:OBRIEN
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 1:8100 OSWEGO ROAD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-652-6551
Mailing Address - Fax:315-652-9698
Practice Address - Street 1:8100 OSWEGO ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-652-6551
Practice Address - Fax:315-652-9698
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01918712Medicaid
080178300OtherRAILROAD MEDICARE
959776OtherMVP HEALTHCARE
CC7712Medicare ID - Type Unspecified
NY01918712Medicaid