Healthcare Provider Details

I. General information

NPI: 1851472534
Provider Name (Legal Business Name): BRENT R.W. MOELLEKEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S SPALDING DR STE 340
BEVERLY HILLS CA
90212-1841
US

IV. Provider business mailing address

545 S PLYMOUTH BLVD
LOS ANGELES CA
90020-4709
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-1001
  • Fax: 310-205-4881
Mailing address:
  • Phone: 310-273-1001
  • Fax: 310-205-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG059781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: