Provider Demographics
NPI:1386225803
Name:ANDERSON, BRIAN MARK
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MARK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 WYNDALE ST APT 333
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4167
Mailing Address - Country:US
Mailing Address - Phone:828-446-1899
Mailing Address - Fax:
Practice Address - Street 1:3855 HEALTH SCIENCES DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-1503
Practice Address - Country:US
Practice Address - Phone:858-246-0886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty