Healthcare Provider Details

I. General information

NPI: 1780639914
Provider Name (Legal Business Name): BRIAN D MADDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 SANTA MONICA BLVD STE 245E
SANTA MONICA CA
90404-2132
US

IV. Provider business mailing address

1821 WILSHIRE BLVD STE 100
SANTA MONICA CA
90403-5627
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8975
  • Fax: 424-291-4108
Mailing address:
  • Phone: 310-575-3100
  • Fax: 310-575-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA70323
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberA70323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: