Healthcare Provider Details

I. General information

NPI: 1235158239
Provider Name (Legal Business Name): DOUGLAS OBRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

3746 FOOTHILL BLVD # B140
GLENDALE CA
91214-1740
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-7000
  • Fax:
Mailing address:
  • Phone: 310-445-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: