Provider Demographics
NPI:1972500999
Name:BRIGHAM, GARY R (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:BRIGHAM
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 1:1009 FOY CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9821
Mailing Address - Country:US
Mailing Address - Phone:219-662-2962
Mailing Address - Fax:
Practice Address - Street 1:1009 FOY CT
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-9821
Practice Address - Country:US
Practice Address - Phone:219-662-2962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041362207RC0001X
IN01041362A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200127970AMedicaid
ING01329Medicare UPIN
IN200127970AMedicaid