Healthcare Provider Details

I. General information

NPI: 1194085290
Provider Name (Legal Business Name): BRANDON MICHAEL ISHAQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 TORRANCE BLVD
TORRANCE CA
90503-4607
US

IV. Provider business mailing address

4101 TORRANCE BLVD
TORRANCE CA
90503-4607
US

V. Phone/Fax

Practice location:
  • Phone: 310-303-5750
  • Fax:
Mailing address:
  • Phone: 310-303-5750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA126413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: