Provider Demographics
NPI:1851472534
Name:MOELLEKEN, BRENT RW (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RW
Last Name:MOELLEKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 S PLYMOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4709
Mailing Address - Country:US
Mailing Address - Phone:310-273-1001
Mailing Address - Fax:310-205-4881
Practice Address - Street 1:120 S SPALDING DR STE 340
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1841
Practice Address - Country:US
Practice Address - Phone:310-273-1001
Practice Address - Fax:310-205-4881
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG059781208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG59781AMedicare ID - Type UnspecifiedIDENTIFICATION NUMBER
CAF08988Medicare UPIN