Healthcare Provider Details

I. General information

NPI: 1053451518
Provider Name (Legal Business Name): JORDAN C DESCHAMPS-BRALY MD, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 POST ST STE 901
SAN FRANCISCO CA
94108-4988
US

IV. Provider business mailing address

360 POST ST STE 901
SAN FRANCISCO CA
94108-4988
US

V. Phone/Fax

Practice location:
  • Phone: 415-624-3922
  • Fax:
Mailing address:
  • Phone: 415-624-3922
  • Fax: 415-276-9382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA-121399
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA121399
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24625
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: