Provider Demographics
NPI:1639475759
Name:BRIAN R. GANTWERKER, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BRIAN R. GANTWERKER, M.D., A MEDICAL CORPORATION
Other - Org Name:THE CRANIOSPINAL CENTER OF LOS ANGELES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:GANTWERKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-694-8300
Mailing Address - Street 1:PO BOX 492209
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2209
Mailing Address - Country:US
Mailing Address - Phone:310-694-8300
Mailing Address - Fax:310-694-8357
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 840
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4807
Practice Address - Country:US
Practice Address - Phone:310-694-8300
Practice Address - Fax:310-694-8357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109316207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty