Healthcare Provider Details

I. General information

NPI: 1750352803
Provider Name (Legal Business Name): OLAF BRANDT NORDLING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 ZION AVENUE KAISER PERMANENTE MEDICAL CENTER SAN DIEGO
SAN DIEGO CA
92112
US

IV. Provider business mailing address

6073 MADRA AVE
SAN DIEGO CA
92120-3943
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-6973
  • Fax: 619-528-3361
Mailing address:
  • Phone: 619-463-5811
  • Fax: 619-528-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberG68208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: