Provider Demographics
NPI:1780861443
Name:BRIAN D. BRANTNER, M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRIAN D. BRANTNER, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRANTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-653-6765
Mailing Address - Street 1:3555 LOMA VISTA RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3161
Mailing Address - Country:US
Mailing Address - Phone:805-653-6765
Mailing Address - Fax:805-653-1470
Practice Address - Street 1:3555 LOMA VISTA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3161
Practice Address - Country:US
Practice Address - Phone:805-653-6765
Practice Address - Fax:805-653-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG027037261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG02-7037OtherMEDICARE ID- TYPE UNSPECIFIRED