Provider Demographics
NPI:1194834879
Name:FENMORE, BRIAN KEITH (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:FENMORE
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 1:18344 CLARK ST
Mailing Address - Street 2:#202
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3505
Mailing Address - Country:US
Mailing Address - Phone:818-708-8011
Mailing Address - Fax:818-708-8826
Practice Address - Street 1:18344 CLARK ST
Practice Address - Street 2:SUITE 202
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3505
Practice Address - Country:US
Practice Address - Phone:818-708-8011
Practice Address - Fax:818-708-8826
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA043642207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B50510Medicare UPIN
CAA43642Medicare ID - Type Unspecified
CAAV811YMedicare PIN