Provider Demographics
NPI:1376655142
Name:BRAZINA, GARY (M D)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:BRAZINA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13160 MINDANAO WAY
Mailing Address - Street 2:STE 300
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6358
Mailing Address - Country:US
Mailing Address - Phone:310-821-2222
Mailing Address - Fax:310-823-5871
Practice Address - Street 1:13160 MINDANAO WAY
Practice Address - Street 2:STE 300
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6358
Practice Address - Country:US
Practice Address - Phone:310-821-2222
Practice Address - Fax:310-823-5871
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37830174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37830OtherMEDICAL LICENSE
CAG37830OtherMEDICAL LICENSE