Provider Demographics
NPI:1275698052
Name:MICHAEL, BRENT JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:JAMES
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2001 SANTA MONICA BLVD STE 470W
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2181
Mailing Address - Country:US
Mailing Address - Phone:310-829-7777
Mailing Address - Fax:310-829-9951
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 470W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2181
Practice Address - Country:US
Practice Address - Phone:310-829-7777
Practice Address - Fax:310-829-9951
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11672120OtherPACIFICCARE
0018000940001OtherONE HEALTH PLAN
0EL054OtherBLUE CROSS OF CA
105958OtherHEALTH NET
00A815910OtherBLUE SHIELD HMO
906487OtherCIGNA
QX0297OtherSR
7410555OtherAETNA
7410555OtherAETNA
0EL054OtherBLUE CROSS OF CA