Provider Demographics
NPI:1003953530
Name:BRIAN K. ESTWICK, M.D., INC.
Entity Type:Organization
Organization Name:BRIAN K. ESTWICK, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:ESTWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-390-2420
Mailing Address - Street 1:2640 29TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2916
Mailing Address - Country:US
Mailing Address - Phone:310-568-8579
Mailing Address - Fax:310-450-9368
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 430
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:310-390-2420
Practice Address - Fax:310-392-2364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41775207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A417750Medicaid
CA1003889247OtherPERSONAL NPI
CA00A417750Medicaid
CAE24774Medicare UPIN