Healthcare Provider Details

I. General information

NPI: 1811929243
Provider Name (Legal Business Name): BRYCE D BESETH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N 13TH AVE STE 204
UPLAND CA
91786-4965
US

IV. Provider business mailing address

510 N 13TH AVE STE 204
UPLAND CA
91786-4965
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-0525
  • Fax: 909-920-0526
Mailing address:
  • Phone: 909-920-0525
  • Fax: 909-920-0526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA65402
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA65402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: