Healthcare Provider Details

I. General information

NPI: 1790889863
Provider Name (Legal Business Name): ANTONIUS D BRANDON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5887 BROCKTON AVE RIVERSIDE PSYCHIATRIC MEDICAL GROUP STE A
RIVERSIDE CA
92506
US

IV. Provider business mailing address

5887 BROCKTON AVE RIVERSIDE PSYCHIATRIC MEDICAL GROUP STE A
RIVERSIDE CA
92506
US

V. Phone/Fax

Practice location:
  • Phone: 951-275-8500
  • Fax: 951-275-8560
Mailing address:
  • Phone: 951-275-8500
  • Fax: 951-275-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY12281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: