Provider Demographics
NPI:1629289178
Name:FOGEL, BRENT LINDEN (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:LINDEN
Last Name:FOGEL
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLAZA SUITE B200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-794-1195
Practice Address - Fax:310-794-7491
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA904932084P0005X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A904930Medicaid
CAWA90493AMedicare PIN
CA00A904930Medicaid