Provider Demographics
NPI:1730474933
Name:LONDON, BRETT MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:MICHAEL
Last Name:LONDON
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 1:130 SUTTER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-4009
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:415-520-0904
Practice Address - Street 1:1801 SHATTUCK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1871
Practice Address - Country:US
Practice Address - Phone:510-225-1025
Practice Address - Fax:510-225-1019
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL-4021390200000X
CA13489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program