Basic Information
| Provider Information | |||||||||
| NPI: | 1750364493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RONSON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 512185 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900510185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267753514 | ||||||||
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| Practice Location | |||||||||
| Address1: | 44274 GEORGE CUSHMAN CT STE 100 | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925925903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512529300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | A77586 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 174400000X | A77586 | CA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00A775860 | 05 | CA | MEDICAID |