Healthcare Provider Details

I. General information

NPI: 1609653492
Provider Name (Legal Business Name): BRANDON LY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date: 03/21/2025
Reactivation Date: 03/27/2025

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

9950 W TROPICANA AVE APT 3016
LAS VEGAS NV
89147-8549
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3550
  • Fax:
Mailing address:
  • Phone: 702-738-2369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: