Healthcare Provider Details

I. General information

NPI: 1427309749
Provider Name (Legal Business Name): TRI VALLEY UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 E ELDER ST SUITE 201
FALLBROOK CA
92028-3081
US

IV. Provider business mailing address

25495 MEDICAL CENTER DR SUITE 204
MURRIETA CA
92562-4902
US

V. Phone/Fax

Practice location:
  • Phone: 951-698-1901
  • Fax: 951-698-1074
Mailing address:
  • Phone: 951-698-1901
  • Fax: 951-698-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILIP P BRODAK
Title or Position: PARTNER
Credential: MD
Phone: 951-698-1901