Healthcare Provider Details

I. General information

NPI: 1760019087
Provider Name (Legal Business Name): MICAH JAMES BRAINERD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST STE 710E
LOS ANGELES CA
90048-5911
US

IV. Provider business mailing address

8631 W 3RD ST STE 710E
LOS ANGELES CA
90048-5911
US

V. Phone/Fax

Practice location:
  • Phone: 989-574-8672
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA203220
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: