Basic Information
| Provider Information | |||||||||
| NPI: | 1558407510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANNOORD | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANNOORD | ||||||||
| OtherFirstName: | BRANDON | ||||||||
| OtherMiddleName: | ALAN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9850 GENESEE AVE STE 320 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585541212 | ||||||||
| FaxNumber: | 8585541222 | ||||||||
| Practice Location | |||||||||
| Address1: | 3969 4TH AVE STE 208 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921033165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6198495777 | ||||||||
| FaxNumber: | 6198495776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/11/2019 | ||||||||
| NPIReactivationDate: | 02/15/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | A113568 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208D00000X | 23831 | NE | N | Allopathic & Osteopathic Physicians | General Practice | 208VP0014X | A113568 | CA | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.