1194772202 NPI number — WETTSTEIN SAWAN MEDICAL GROUP INC

Table of content: DUNCAN LEE BRALTS DO (NPI 1407485097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194772202 NPI number — WETTSTEIN SAWAN MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WETTSTEIN SAWAN MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194772202
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12370 HESPERIA RD
Provider Second Line Business Mailing Address:
SUITE 15
Provider Business Mailing Address City Name:
VICTORVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92395-7719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-241-7773
Provider Business Mailing Address Fax Number:
760-241-7793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12370 HESPERIA RD
Provider Second Line Business Practice Location Address:
SUITE 15
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-7719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-241-7773
Provider Business Practice Location Address Fax Number:
760-241-7793
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NEAL
Authorized Official First Name:
PEGGY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLER
Authorized Official Telephone Number:
760-241-7773

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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