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General NPI Number Information
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NPI Number | 1891954772
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Entity Type | Individual
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Provider Name | BRENT LEONG LUM M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/05/2008
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Last Update Date | 12/15/2021
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Provider Practice Location Address
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Address Line | 4601 DALE RD
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City | MODESTO
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State | CA
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Zip | 95356-9718
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Country | US
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Telephone | 209-476-3484
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Fax | 209-476-3012
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Provider Business Mailing Address
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Address Line | 3650 SOMERSET AVE
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City | CASTRO VALLEY
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State | CA
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Zip | 94546-3439
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Country | US
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Telephone | 510-886-2503
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | BP1-0032047
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | A116550
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License Number State | CA
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