Provider Demographics
NPI:1679500912
Name:SPANN, BRYAN MICHAEL-PAUL (DO)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:MICHAEL-PAUL
Last Name:SPANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE #57454
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:323-442-5710
Mailing Address - Fax:323-442-5729
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 3000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5710
Practice Address - Fax:323-442-5729
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A73702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX73700Medicaid
CAW20A7370AMedicare ID - Type UnspecifiedMEDICARE INDIV. #
CA00AX73700Medicaid