Provider Demographics
NPI:1700216488
Name:WALTER D BRAMSON MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WALTER D BRAMSON MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BRAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-338-1851
Mailing Address - Street 1:PO BOX 3816
Mailing Address - Street 2:580 FOREST SHADE RD UNIT 1
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-3816
Mailing Address - Country:US
Mailing Address - Phone:909-338-1851
Mailing Address - Fax:909-338-6381
Practice Address - Street 1:580 FOREST SHADE RD UNIT 1
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325-3816
Practice Address - Country:US
Practice Address - Phone:909-338-1851
Practice Address - Fax:909-338-6381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40647261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48301Medicare UPIN