Provider Demographics
NPI:1639165111
Name:MOTT, BRIAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:MOTT
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 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:720 MADISON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1609
Practice Address - Country:US
Practice Address - Phone:570-343-1115
Practice Address - Fax:570-343-5865
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073573L208G00000X
PAMD-073573L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01844694Medicaid
PA047968ZGLMedicare PIN
PAH38162Medicare UPIN