Provider Demographics
NPI:1598953960
Name:BRENTON D. WYNN, MD INC
Entity Type:Organization
Organization Name:BRENTON D. WYNN, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR
Authorized Official - Phone:619-318-8233
Mailing Address - Street 1:502 EUCLID AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2984
Mailing Address - Country:US
Mailing Address - Phone:619-434-4019
Mailing Address - Fax:619-461-5663
Practice Address - Street 1:502 EUCLID AVE STE 200
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2984
Practice Address - Country:US
Practice Address - Phone:619-434-4019
Practice Address - Fax:619-461-5663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA732572081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18884Medicare PIN