Healthcare Provider Details

I. General information

NPI: 1336551084
Provider Name (Legal Business Name): BRENT WILLARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E. VANDERBILT WAY
SAN BERNARDINO CA
92415-0026
US

IV. Provider business mailing address

25571 LANE ST
LOMA LINDA CA
92354-2412
US

V. Phone/Fax

Practice location:
  • Phone: 909-387-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA142234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: