Provider Demographics
NPI:1457354391
Name:GAW, BRIAN KIMKYONE
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KIMKYONE
Last Name:GAW
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 1:1669 W AVENUE J
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2866
Mailing Address - Country:US
Mailing Address - Phone:661-951-7888
Mailing Address - Fax:661-951-8889
Practice Address - Street 1:1669 W AVENUE J
Practice Address - Street 2:SUITE 304
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2866
Practice Address - Country:US
Practice Address - Phone:661-951-7888
Practice Address - Fax:661-951-8889
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28727208000000X
CAA49005208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A490050Medicaid
KY64287279Medicaid
KY64287279Medicaid
CA00A490050Medicaid