Provider Demographics
NPI:1720080369
Name:LOVERIDGE, BRIAN WILLARD (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLARD
Last Name:LOVERIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 KATY FWY STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-1902
Mailing Address - Country:US
Mailing Address - Phone:281-600-5000
Mailing Address - Fax:281-605-6705
Practice Address - Street 1:2086 N 1700 W STE D
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1164
Practice Address - Country:US
Practice Address - Phone:385-515-4100
Practice Address - Fax:385-351-1150
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10269207P00000X, 207PE0004X
UT1205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018840Medicaid
H52591Medicare UPIN
NV002018840Medicaid