Basic Information
| Provider Information | |||||||||
| NPI: | 1306896691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOWELL | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098838611 | ||||||||
| FaxNumber: | 9098815707 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098838611 | ||||||||
| FaxNumber: | 9098815707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A54025 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A540251 | 05 | CA | MEDICAID |