Provider Demographics
NPI:1245422658
Name:SOMOANO, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:SOMOANO
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 1:2141 N HARBOR BLVD
Mailing Address - Street 2:SUITE 25000
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3827
Mailing Address - Country:US
Mailing Address - Phone:714-626-8610
Mailing Address - Fax:714-626-8655
Practice Address - Street 1:2141 N HARBOR BLVD
Practice Address - Street 2:SUITE 25000
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3827
Practice Address - Country:US
Practice Address - Phone:714-626-8610
Practice Address - Fax:714-626-8655
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97409207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADR489ZMedicare PIN