=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629003256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICIA A BROTMAN M.D. A PROFESSIONAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 08/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15944 LOS SERRANOS COUNTRY CLUB DR STE 180
-----------------------------------------------------
City | CHINO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91709-3990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-393-3393
-----------------------------------------------------
Fax | 909-597-7009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15944 LOS SERRANOS COUNTRY CLUB DR STE 180
-----------------------------------------------------
City | CHINO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91709-3990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-393-3393
-----------------------------------------------------
Fax | 909-597-7009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, SECRETARY, C.F.O
-----------------------------------------------------
Name | PATRICIA ARDEN BROTMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 909-393-3393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | G69097
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------