Provider Demographics
NPI:1215945647
Name:O'NEILL, BRIAN FREDERICK (DPM)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:FREDERICK
Last Name:O'NEILL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3029
Mailing Address - Country:US
Mailing Address - Phone:909-622-4501
Mailing Address - Fax:909-632-1729
Practice Address - Street 1:1212 N PARK AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3029
Practice Address - Country:US
Practice Address - Phone:909-622-4501
Practice Address - Fax:909-632-1729
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3029213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E302900Medicaid
CAE3029Medicare UPIN
CAWE3029AMedicare PIN
CA1318040001Medicare NSC
CA000E30290Medicare UPIN
CA000E302900Medicaid
CA000E3029AMedicare UPIN
CA000E302900Medicaid