Healthcare Provider Details

I. General information

NPI: 1205133188
Provider Name (Legal Business Name): BRIAN JASON BROTHERTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 ZONAL AVE RM 112
LOS ANGELES CA
90089-0121
US

IV. Provider business mailing address

2020 ZONAL AVE RM 112
LOS ANGELES CA
90089-0121
US

V. Phone/Fax

Practice location:
  • Phone: 323-226-3688
  • Fax:
Mailing address:
  • Phone: 323-226-3688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA115778
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA115778
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA115778
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: