Provider Demographics
NPI:1649294620
Name:BRISLIN, DONALD MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:MICHAEL
Last Name:BRISLIN
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 1:161 N MAIN ST
Mailing Address - Street 2:PO BOX 263
Mailing Address - City:DUBLIN
Mailing Address - State:PA
Mailing Address - Zip Code:18917-2107
Mailing Address - Country:US
Mailing Address - Phone:215-249-1500
Mailing Address - Fax:215-249-1040
Practice Address - Street 1:161 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:PA
Practice Address - Zip Code:18917-2107
Practice Address - Country:US
Practice Address - Phone:215-249-1500
Practice Address - Fax:215-249-1040
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-008313-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017270800003Medicaid
021280Medicare ID - Type Unspecified
PA0017270800003Medicaid