Provider Demographics
NPI:1912208836
Name:BRYDON, PAUL DOUGLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DOUGLAS
Last Name:BRYDON
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 1:425 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3413
Mailing Address - Country:US
Mailing Address - Phone:760-737-6960
Mailing Address - Fax:
Practice Address - Street 1:41840 ENTERPRISE CIR N
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5654
Practice Address - Country:US
Practice Address - Phone:951-694-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11340390200000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA105400Medicare PIN
CAW14158Medicare Oscar/Certification
CAGU203YMedicare UPIN
CAZZZ20041ZMedicare Oscar/Certification