Provider Demographics
NPI:1679568661
Name:BRISCOE, STEPHEN TREVOR (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:TREVOR
Last Name:BRISCOE
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 1:1470 CUMBERLAND FALLS HWY
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2721
Mailing Address - Country:US
Mailing Address - Phone:606-526-0433
Mailing Address - Fax:606-526-0434
Practice Address - Street 1:1490 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2721
Practice Address - Country:US
Practice Address - Phone:606-526-0433
Practice Address - Fax:606-526-0434
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33339207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64060148Medicaid
TN3809558Medicaid
G24848Medicare UPIN
KY180046277Medicare PIN
KY0773701Medicare PIN
KY0752601Medicare PIN
KY0752801Medicare PIN
TN3809558Medicaid
KY64060148Medicaid