Provider Demographics
NPI:1992942254
Name:GARY BRAZINA MD, INC.
Entity type:Organization
Organization Name:GARY BRAZINA MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRAZINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-821-2222
Mailing Address - Street 1:13160 MINDANAO WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6393
Mailing Address - Country:US
Mailing Address - Phone:310-821-2222
Mailing Address - Fax:310-823-5871
Practice Address - Street 1:13160 MINDANAO WAY STE 300
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6393
Practice Address - Country:US
Practice Address - Phone:310-821-2222
Practice Address - Fax:310-823-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37830174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty