Provider Demographics
NPI:1184763476
Name:BURT BRENT MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:BURT BRENT MD A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-851-5300
Mailing Address - Street 1:2995 WOODSIDE ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2447
Mailing Address - Country:US
Mailing Address - Phone:650-851-5300
Mailing Address - Fax:650-851-5302
Practice Address - Street 1:2995 WOODSIDE ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062-2447
Practice Address - Country:US
Practice Address - Phone:650-851-5300
Practice Address - Fax:650-851-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG260912086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G260910Medicaid
A42897Medicare UPIN
CA00G260910Medicare ID - Type Unspecified