Provider Demographics
NPI:1932788544
Name:MAIJALA, BRANDON CHARLES
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:CHARLES
Last Name:MAIJALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 NEWPORT AVE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-6407
Mailing Address - Country:US
Mailing Address - Phone:909-802-8086
Mailing Address - Fax:
Practice Address - Street 1:11911 ARTESIA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90701-4070
Practice Address - Country:US
Practice Address - Phone:562-402-2489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEL7003213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist