Healthcare Provider Details

I. General information

NPI: 1023021151
Provider Name (Legal Business Name): BRIAN E. O'SHAUGHNESSY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 W DALE ST
WATERLOO IA
50703-1925
US

IV. Provider business mailing address

152 W DALE ST
WATERLOO IA
50703-1925
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-5060
  • Fax: 319-235-5061
Mailing address:
  • Phone: 319-235-5060
  • Fax: 319-235-5061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036-066709
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: