Provider Demographics
NPI:1013113737
Name:WARDWELL, BRIAN NICKERSON (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:NICKERSON
Last Name:WARDWELL
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 1:1000 W CARSON ST
Mailing Address - Street 2:HARBOR UCLA MEDICAL CENTER
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-222-3137
Mailing Address - Fax:
Practice Address - Street 1:HARBOR-UCLA MEDICAL CENTER
Practice Address - Street 2:1000 W CARSON ST
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist