Provider Demographics
NPI:1831196609
Name:CHESNIE, BRIAN MARK (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MARK
Last Name:CHESNIE
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:PO BOX 1728
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-0728
Mailing Address - Country:US
Mailing Address - Phone:949-574-4953
Mailing Address - Fax:949-229-6297
Practice Address - Street 1:1501 SUPERIOR AVE STE 212
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3640
Practice Address - Country:US
Practice Address - Phone:949-574-4953
Practice Address - Fax:949-229-6297
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41393174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330058517OtherTAX ID
CAWC41393DOtherPTAN #
CAA37583Medicare UPIN
CA330058517OtherTAX ID