Provider Demographics
NPI:1487683819
Name:BRZOSTOWICZ, MARY C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:BRZOSTOWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CAMPUS DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4900
Mailing Address - Country:US
Mailing Address - Phone:650-756-8600
Mailing Address - Fax:
Practice Address - Street 1:901 CAMPUS DR
Practice Address - Street 2:SUITE 302
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4900
Practice Address - Country:US
Practice Address - Phone:650-756-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG369130174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G369130Medicaid
CAA46862Medicare UPIN
CA00G369130Medicare ID - Type Unspecified