Provider Demographics
NPI:1720051436
Name:JICK, BRYAN S (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:S
Last Name:JICK
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 1:625 S FAIR OAKS AVE
Mailing Address - Street 2:SUITE 255
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2613
Mailing Address - Country:US
Mailing Address - Phone:626-304-2626
Mailing Address - Fax:626-585-0695
Practice Address - Street 1:625 S FAIR OAKS AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:626-304-2626
Practice Address - Fax:626-585-0695
Is Sole Proprietor?:No
Enumeration Date:2006-02-12
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55140207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology