Healthcare Provider Details

I. General information

NPI: 1033596168
Provider Name (Legal Business Name): JONATHAN BRICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 PARKWAY DR
LA MESA CA
91942
US

IV. Provider business mailing address

11234 ANDERSON ST GME OFFICE WESTERLY SUITE C
LOMA LINDA CA
92350-1716
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A15087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: