Provider Demographics
NPI:1215917752
Name:BRARA, PRABHTEJ SINGH (MD)
Entity type:Individual
Prefix:
First Name:PRABHTEJ
Middle Name:SINGH
Last Name:BRARA
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 1:1301 20TH ST STE 590
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2054
Mailing Address - Country:US
Mailing Address - Phone:310-315-0101
Mailing Address - Fax:310-453-4145
Practice Address - Street 1:1301 20TH ST STE 590
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2054
Practice Address - Country:US
Practice Address - Phone:310-315-0101
Practice Address - Fax:310-453-4145
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA062470174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A624700OtherBC/BS
CA00A624700Medicaid
CA952976030OtherGROUP TAX ID
CAW1249Medicare PIN
CAH45417Medicare UPIN
CAWA62470DMedicare PIN
CA00A624700OtherBC/BS
CAHW1249AMedicare PIN