Provider Demographics
NPI:1790889863
Name:BRANDON, ANTONIUS D (PHD)
Entity Type:Individual
Prefix:
First Name:ANTONIUS
Middle Name:D
Last Name:BRANDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5887 BROCKTON AVE
Mailing Address - Street 2:RIVERSIDE PSYCHIATRIC MEDICAL GROUP STE A
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:951-275-8500
Mailing Address - Fax:951-275-8560
Practice Address - Street 1:5887 BROCKTON AVE
Practice Address - Street 2:RIVERSIDE PSYCHIATRIC MEDICAL GROUP STE A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-275-8500
Practice Address - Fax:951-275-8560
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12281103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL122810Medicare ID - Type Unspecified
S07114Medicare UPIN