Healthcare Provider Details

I. General information

NPI: 1508876699
Provider Name (Legal Business Name): DERALD E BRACKMANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 W 3RD ST STE 111
LOS ANGELES CA
90057-1999
US

IV. Provider business mailing address

2100 W 3RD ST STE 111
LOS ANGELES CA
90057-1999
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-9930
  • Fax: 213-483-0905
Mailing address:
  • Phone: 213-483-9930
  • Fax: 213-483-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberG11124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: