Provider Demographics
NPI:1831262203
Name:WATANABE, BRIAN I (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:I
Last Name:WATANABE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24953 PASEO DE VALENCIA
Mailing Address - Street 2:SUITE 15C
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4342
Mailing Address - Country:US
Mailing Address - Phone:949-770-9300
Mailing Address - Fax:949-770-9310
Practice Address - Street 1:24953 PASEO DE VALENCIA
Practice Address - Street 2:SUITE 15C
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4342
Practice Address - Country:US
Practice Address - Phone:949-770-9300
Practice Address - Fax:949-770-9310
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG834232086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CS338YOtherMEDICARE PTAN
CA1417286980OtherCORPORATION NPI
CS338YOtherMEDICARE PTAN
G83423 AMedicare ID - Type Unspecified