Provider Demographics
NPI:1760687560
Name:DALE J BRENT MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DALE J BRENT MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-784-1195
Mailing Address - Street 1:4955 VAN NUYS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1812
Mailing Address - Country:US
Mailing Address - Phone:818-784-1195
Mailing Address - Fax:818-784-6473
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:SUITE 411
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-784-1195
Practice Address - Fax:818-784-7026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43070207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14870Medicare ID - Type Unspecified
CAB50504Medicare UPIN