Provider Demographics
NPI:1013444512
Name:MAVRETICH, BRIAN LAWRENCE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LAWRENCE
Last Name:MAVRETICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4385 48TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-4611
Mailing Address - Country:US
Mailing Address - Phone:248-420-9942
Mailing Address - Fax:727-497-2322
Practice Address - Street 1:6333 54TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1703
Practice Address - Country:US
Practice Address - Phone:727-548-6100
Practice Address - Fax:727-497-2322
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS17981208VP0014X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine