Provider Demographics
NPI:1679764534
Name:DEFADE, BRIAN PHILIP (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PHILIP
Last Name:DEFADE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SAINT CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7087
Mailing Address - Country:US
Mailing Address - Phone:606-833-3333
Mailing Address - Fax:606-833-4668
Practice Address - Street 1:1101 SAINT CHRISTOPHER DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7087
Practice Address - Country:US
Practice Address - Phone:606-833-3333
Practice Address - Fax:606-833-4668
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03268208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3062680Medicaid
KY000000665202OtherANTHEM BCBS
KY7100120830Medicaid
KY000000665202OtherANTHEM BCBS