Healthcare Provider Details

I. General information

NPI: 1982995635
Provider Name (Legal Business Name): BRENT R. LIVINGSTON, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 HEALTH CENTER DR
SAN DIEGO CA
92123-2700
US

IV. Provider business mailing address

PO BOX 8403
RANCHO SANTA FE CA
92067-8403
US

V. Phone/Fax

Practice location:
  • Phone: 858-939-3400
  • Fax:
Mailing address:
  • Phone: 619-540-4180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG24378
License Number StateCA

VIII. Authorized Official

Name: MR. BRENT R. LIVINGSTON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-540-4180