Provider Demographics
NPI:1881703809
Name:PIAZZA, BRIAN L (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:PIAZZA
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 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 LAKE AVE STE 104
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-948-5170
Practice Address - Fax:574-948-5498
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBP056021208600000X
IN01066413A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200980180Medicaid
MI3510115Medicaid
F54748Medicare UPIN
MI3510115Medicaid
M400034821Medicare PIN
M72340003Medicare ID - Type Unspecified