Provider Demographics
NPI:1306818463
Name:BRILLIANT, LAWRENCE C (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:C
Last Name:BRILLIANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-2136
Mailing Address - Country:US
Mailing Address - Phone:609-365-5333
Mailing Address - Fax:
Practice Address - Street 1:595 W STATE ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2554
Practice Address - Country:US
Practice Address - Phone:215-345-2362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194612207P00000X
PAMD056072E207P00000X
NJ25MA06961300207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015420580005Medicaid
PA703134Medicare ID - Type Unspecified
PA0015420580005Medicaid