Provider Demographics
NPI:1003927872
Name:JOEY BRETT MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JOEY BRETT MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-789-0034
Mailing Address - Street 1:12400 VENTURA BLVD
Mailing Address - Street 2:# 738
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2406
Mailing Address - Country:US
Mailing Address - Phone:818-789-0034
Mailing Address - Fax:818-789-0042
Practice Address - Street 1:13320 RIVERSIDE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2502
Practice Address - Country:US
Practice Address - Phone:818-789-0034
Practice Address - Fax:818-789-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003927872OtherNPI
CA00A551020OtherMEDI-CAL NUMBER
CA1003927872OtherNPI
CAWA55102CMedicare ID - Type UnspecifiedMEDICARE PPIN
CAW19261Medicare ID - Type UnspecifiedGRP MEDICARE NUMBER