Provider Demographics
NPI:1811929243
Name:BESETH, BRYCE D (MD)
Entity type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:D
Last Name:BESETH
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 1:510 N 13TH AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4965
Mailing Address - Country:US
Mailing Address - Phone:909-920-0525
Mailing Address - Fax:909-920-0526
Practice Address - Street 1:510 N 13TH AVE
Practice Address - Street 2:STE 204
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4965
Practice Address - Country:US
Practice Address - Phone:909-920-0525
Practice Address - Fax:909-920-0526
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65402208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI36106Medicare UPIN
00A654020Medicare ID - Type Unspecified