Provider Demographics
NPI:1659641702
Name:JONATHAN LEONARD BRAND, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JONATHAN LEONARD BRAND, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:BRAND
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:310-306-6150
Mailing Address - Street 1:4314 MARINA CITY DR
Mailing Address - Street 2:SUITE 1118CTS
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5816
Mailing Address - Country:US
Mailing Address - Phone:310-306-6150
Mailing Address - Fax:310-645-5532
Practice Address - Street 1:3630 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2636
Practice Address - Country:US
Practice Address - Phone:310-701-7830
Practice Address - Fax:310-645-5532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG500452084P0802X
CA273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
No273R00000XHospital UnitsPsychiatric UnitGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G500451Medicaid
CAG50045Medicare PIN