Provider Demographics
NPI:1982689949
Name:PRZYSTAWSKI, BRIAN (DPM, PSC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:PRZYSTAWSKI
Suffix:
Gender:M
Credentials:DPM, PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-0708
Mailing Address - Country:US
Mailing Address - Phone:502-454-4187
Mailing Address - Fax:502-454-4235
Practice Address - Street 1:4119 BROWNS LN
Practice Address - Street 2:BLDG 2
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1500
Practice Address - Country:US
Practice Address - Phone:502-454-4187
Practice Address - Fax:502-454-4235
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000635213ES0103X
KY195213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1054641Medicaid
611327502OtherHUMANA
611327502OtherTRICARE NORTH
IN000000051908OtherANTHEM
KY80001951Medicaid
000000051908OtherUNICARE
KY000000051908OtherANTHEM
IN215680OtherMEDICARE GROUP
480027403OtherRAILROAD MEDICARE
KY9209OtherMEDICARE GROUP
000000051908OtherIN COMPREHENSIVE
2433700000OtherPASSPORT ADVANTAGE
611327502OtherTRICARE NORTH
2433700000OtherPASSPORT ADVANTAGE
IN000000051908OtherANTHEM