Provider Demographics
NPI:1164493284
Name:NORMAN, BRENT C (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:C
Last Name:NORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 HOSPITAL RD
Mailing Address - Street 2:SUITE 126
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3522
Mailing Address - Country:US
Mailing Address - Phone:949-722-3980
Mailing Address - Fax:949-722-3989
Practice Address - Street 1:361 HOSPITAL RD
Practice Address - Street 2:SUITE 126
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3522
Practice Address - Country:US
Practice Address - Phone:949-722-3980
Practice Address - Fax:949-722-3989
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42762207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42762Medicare ID - Type Unspecified
CAD40767Medicare UPIN