Provider Demographics
NPI:1700853850
Name:LOOS, BRYAN D (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:LOOS
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 1:960 CLAGUE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1582
Mailing Address - Country:US
Mailing Address - Phone:440-250-5366
Mailing Address - Fax:
Practice Address - Street 1:960 CLAGUE RD STE 110B
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1582
Practice Address - Country:US
Practice Address - Phone:440-250-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4511OtherRR MEDICARE GROUP
107559OtherKAISER
1780634279OtherGROUP NPI
0119204OtherGROUP MEDICAID
080167222OtherRR MEDICARE INDIVIDUAL
10795128OtherCAQH
34-1783789OtherGROUP TIN
34-1783789OtherGROUP TIN
0119204OtherGROUP MEDICAID
107559OtherKAISER
D368301OtherGROUP IND DIAGNOSTICS MED