Provider Demographics
NPI:1811204647
Name:IDA, BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:IDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 INDIAN ROCKS RD S
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-1035
Mailing Address - Country:US
Mailing Address - Phone:727-586-7103
Mailing Address - Fax:727-585-7205
Practice Address - Street 1:2025 INDIAN ROCKS RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774
Practice Address - Country:US
Practice Address - Phone:727-586-7103
Practice Address - Fax:727-585-7205
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO2457207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology