Healthcare Provider Details

I. General information

NPI: 1578026167
Provider Name (Legal Business Name): BRIAN CHARLES BOURSIQUOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-6262
  • Fax:
Mailing address:
  • Phone: 212-305-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number317526-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: