Healthcare Provider Details

I. General information

NPI: 1437669694
Provider Name (Legal Business Name): BRANDON GEORGE MCMAHAN IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10172 KEPPLER DR
SAN DIEGO CA
92124-2504
US

IV. Provider business mailing address

10172 KEPPLER DR
SAN DIEGO CA
92124-2504
US

V. Phone/Fax

Practice location:
  • Phone: 561-628-8901
  • Fax:
Mailing address:
  • Phone: 561-628-8901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: