Provider Demographics
NPI:1679747448
Name:BRETT A GIDNEY MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BRETT A GIDNEY MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:GIDNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-287-7060
Mailing Address - Street 1:5555 RESERVOIR DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5134
Mailing Address - Country:US
Mailing Address - Phone:619-287-7060
Mailing Address - Fax:
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:SUITE 112
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-287-7060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81336207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA81336OtherSTATE LICENSE
BG8116798OtherDEA