MEDICARE: DR. BRIAN RANDALL GANTWERKER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	A109316	CA

General Provider Information

NPI Number	:	1609842715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN RANDALL GANTWERKER M.D.

Provider Business Mailing Address
First Line	:	PO BOX 492209
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-2209
Country	:	US
Telephone Number	:	310-694-8300
Fax Number	:	310-694-8357

Provider Business Practice Location Address
First Line	:	2811 WILSHIRE BLVD
Second Line	:	SUITE 840
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4803
Country	:	US
Telephone Number	:	310-694-8300
Fax Number	:	310-694-8357

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	06/14/2016

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