Healthcare Provider Details

I. General information

NPI: 1265182190
Provider Name (Legal Business Name): BRIAN WOLLOCKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 RADIO WAY
MASON OH
45040-4520
US

IV. Provider business mailing address

2601 OCEAN PKWY
BROOKLYN NY
11235-7791
US

V. Phone/Fax

Practice location:
  • Phone: 513-984-5133
  • Fax:
Mailing address:
  • Phone: 718-616-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: