Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | C031243 | CA |
N | 207ND0900X | Dermatopathologist | C031243 | CA |
N | 207NP0225X | Pediatric Dermatologist | C031243 | CA |
N | 207NS0135X | Procedural Dermatology | C031243 | CA |
NPI | 1285732388 |
---|---|
Provider Name | Dr. Gary Bradford Klein |
First Address | Valencia, CA 91355-2058 |
Second Address | Valencia, CA 91355-2058 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 27/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
953527990 | TAX ID (01) | CA |
A34488 | (02) | CA |
AK0041652 | DEA CERTIFICATE # (01) | CA |
C031243 | STATE LICENSE (01) | CA |