Provider Demographics
NPI:1427089911
Name:BRENTWOOD DERMATOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:BRENTWOOD DERMATOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:SILVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-826-2051
Mailing Address - Street 1:11980 SAN VICENTE BLVD.
Mailing Address - Street 2:SUITE # 120
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:310-826-2051
Mailing Address - Fax:310-979-0185
Practice Address - Street 1:11980 SAN VICENTE BLVD
Practice Address - Street 2:SUITE # 120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5012
Practice Address - Country:US
Practice Address - Phone:310-826-2051
Practice Address - Fax:310-979-0185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty