1558407510 NPI number — DR. BRANDON A VANNOORD MD

Table of content: DR. BRANDON A VANNOORD MD (NPI 1558407510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558407510 NPI number — DR. BRANDON A VANNOORD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANNOORD
Provider First Name:
BRANDON
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANNOORD
Provider Other First Name:
BRANDON
Provider Other Middle Name:
ALAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1558407510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/11/2019
NPI Reactivation Date:
02/15/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9850 GENESEE AVE STE 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-554-1212
Provider Business Mailing Address Fax Number:
858-554-1222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3969 4TH AVE STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-3165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-849-5777
Provider Business Practice Location Address Fax Number:
619-849-5776
Provider Enumeration Date:
01/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  A113568 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 23831 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: A113568 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)