Provider Demographics
NPI:1710175807
Name:FREUD, BRIAN DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
Last Name:FREUD
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2925 LBJ FRWY #100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7608
Mailing Address - Country:US
Mailing Address - Phone:732-690-1196
Mailing Address - Fax:972-280-0081
Practice Address - Street 1:7777 FOREST LANE
Practice Address - Street 2:B-115
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-566-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009311-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ17815Medicare UPIN