Provider Demographics
NPI:1740261387
Name:BRIGHAM, MARK STEVEN (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:BRIGHAM
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 1:195 WADSWORTH RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-9504
Mailing Address - Country:US
Mailing Address - Phone:330-336-8717
Mailing Address - Fax:330-335-0092
Practice Address - Street 1:195 WADSWORTH RD
Practice Address - Street 2:SUITE 401
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-9504
Practice Address - Country:US
Practice Address - Phone:330-336-8717
Practice Address - Fax:330-335-0092
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005567207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0180398Medicaid
OH0180398Medicaid