Provider Demographics
NPI:1497747588
Name:LOS, BRIAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:LOS
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 1:339 W SPRING ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1655
Mailing Address - Country:US
Mailing Address - Phone:814-827-9695
Mailing Address - Fax:814-827-0216
Practice Address - Street 1:339 W SPRING ST
Practice Address - Street 2:SUITE 102
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1655
Practice Address - Country:US
Practice Address - Phone:814-827-9695
Practice Address - Fax:814-827-0216
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060387L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016335370004Medicaid
PA0016335370004Medicaid
767821K85Medicare ID - Type Unspecified