Healthcare Provider Details

I. General information

NPI: 1316073455
Provider Name (Legal Business Name): WASHINGTON BRYAN II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11669 SANTA MONICA BLVD STE 110
LOS ANGELES CA
90025-2929
US

IV. Provider business mailing address

11669 SANTA MONICA BLVD STE 110
LOS ANGELES CA
90025-2929
US

V. Phone/Fax

Practice location:
  • Phone: 310-228-3652
  • Fax: 310-499-4177
Mailing address:
  • Phone: 310-228-3652
  • Fax: 310-499-4177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number61799
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number61799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: