Healthcare Provider Details

I. General information

NPI: 1477627248
Provider Name (Legal Business Name): BRENDA GAI.L BASS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 W SUNSET BLVD STE 408
LOS ANGELES CA
90069-3705
US

IV. Provider business mailing address

9201 W SUNSET BLVD STE 408
LOS ANGELES CA
90069-3705
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-7201
  • Fax: 310-273-7326
Mailing address:
  • Phone: 310-273-7201
  • Fax: 310-273-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA35872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: