Healthcare Provider Details

I. General information

NPI: 1013411859
Provider Name (Legal Business Name): IAN MICHAEL BRASTAUSKAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 SUNSET BLVD STE 400
WEST COLUMBIA SC
29169-4872
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-7095
  • Fax: 803-936-7908
Mailing address:
  • Phone: 803-936-7095
  • Fax: 803-936-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number96678
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: