Healthcare Provider Details

I. General information

NPI: 1902858343
Provider Name (Legal Business Name): ALFONSO BRIGHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/07/2023
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11633 HAWTHORNE BLVD SUITE 410
HAWTHORNE CA
90250-2321
US

IV. Provider business mailing address

4161 REDONDO BEACH BLVD SUITE 201
LAWNDALE CA
90260-3306
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-4450
  • Fax: 310-792-4455
Mailing address:
  • Phone: 310-214-8677
  • Fax: 310-921-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG48631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: