Provider Demographics
NPI:1558476887
Name:DODD, BRIAN S (PAC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:DODD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 SHARON AVE NW
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-4326
Mailing Address - Country:US
Mailing Address - Phone:828-758-7091
Mailing Address - Fax:828-758-7058
Practice Address - Street 1:232 SHARON AVE NW
Practice Address - Street 2:SUITE 400
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-4326
Practice Address - Country:US
Practice Address - Phone:828-758-7091
Practice Address - Fax:828-758-7058
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA331363A00000X
NC0010-04342363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010030444OtherREGENCE BLUE SHIELD
000010162910OtherREGENCE BLUE SHIELD
WA029674OtherWA DEPARTMENT OF LABOR
PAF45OtherBLUE CROSS OF IDAHO
IDPAMD9OtherBLUE CROSS OF IDAHO
OR194498OtherOMAP
ID806341400Medicaid
ID8K248OtherBLUE CROSS OF IDAHO GROUP
ID1667064Medicare PIN
IDPAMD9OtherBLUE CROSS OF IDAHO
OR194498OtherOMAP