Healthcare Provider Details

I. General information

NPI: 1619213428
Provider Name (Legal Business Name): DESCHAMPS-BRALY CLINIC OF PLASTIC AND CRANIOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
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: 415-276-9382
Mailing address:
  • Phone: 415-624-3922
  • Fax: 415-276-9382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA121399
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA-121399
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JORDAN DESCHAMPS-BRALY
Title or Position: OWNER
Credential: MD
Phone: 415-624-3922