Provider Demographics
NPI:1528562527
Name:GEFFEN, BRENT JACOB (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:JACOB
Last Name:GEFFEN
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 1:2876 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1530
Mailing Address - Country:US
Mailing Address - Phone:805-379-9646
Mailing Address - Fax:
Practice Address - Street 1:2876 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1530
Practice Address - Country:US
Practice Address - Phone:805-379-9646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA185833207Y00000X
UT11393298-1205207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology