Healthcare Provider Details

I. General information

NPI: 1215921028
Provider Name (Legal Business Name): MARIO IGNACIO BRAKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 ELM AVE STE 318
LONG BEACH CA
90806-1600
US

IV. Provider business mailing address

2650 ELM AVE STE 318
LONG BEACH CA
90806-1600
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-0166
  • Fax: 562-595-6714
Mailing address:
  • Phone: 562-595-0166
  • Fax: 562-595-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberA-33396
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: