1427089911 NPI number — BRENTWOOD DERMATOLOGY MEDICAL GROUP

Table of content: (NPI 1427089911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427089911 NPI number — BRENTWOOD DERMATOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRENTWOOD DERMATOLOGY MEDICAL GROUP
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:
1427089911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11980 SAN VICENTE BLVD.
Provider Second Line Business Mailing Address:
SUITE # 120
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-826-2051
Provider Business Mailing Address Fax Number:
310-979-0185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11980 SAN VICENTE BLVD
Provider Second Line Business Practice Location Address:
SUITE # 120
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90049-5012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-826-2051
Provider Business Practice Location Address Fax Number:
310-979-0185
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SILVERS
Authorized Official First Name:
JACK
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-826-2051

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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