Healthcare Provider Details

I. General information

NPI: 1467713354
Provider Name (Legal Business Name): BRIAN JACOBS SHIOZAWA MD, MPH, MHA, FACOEM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BRULE ST BLDG 871
FORT KNOX KY
40121-6100
US

IV. Provider business mailing address

200 BRULE ST BLDG 871
FORT KNOX KY
40121-6100
US

V. Phone/Fax

Practice location:
  • Phone: 502-626-9743
  • Fax:
Mailing address:
  • Phone: 502-626-9743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberP9732
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberP9732
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: