Provider Demographics
NPI:1700204989
Name:BRANDAL, GARTH
Entity Type:Individual
Prefix:
First Name:GARTH
Middle Name:
Last Name:BRANDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 TORRANCE BLVD
Mailing Address - Street 2:RADIOLOGY DEPT
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-3370
Mailing Address - Country:US
Mailing Address - Phone:310-303-5750
Mailing Address - Fax:
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-303-5750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAA1399482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program