Healthcare Provider Details

I. General information

NPI: 1447255963
Provider Name (Legal Business Name): BRIAN S MCLEOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CANTERBURY RD
BROOKLYN CT
06234-1901
US

IV. Provider business mailing address

63 CANTERBURY RD
BROOKLYN CT
06234-1901
US

V. Phone/Fax

Practice location:
  • Phone: 860-412-0491
  • Fax: 860-412-0496
Mailing address:
  • Phone: 860-412-0491
  • Fax: 860-412-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD08941
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number046626
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: