Basic Information
| Provider Information | |||||||||
| NPI: | 1912004367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IZU | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | SEIJI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4053 LONE TREE WAY | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945316210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257767725 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4053 LONE TREE WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945316210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257767725 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35.088603 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 1012919 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | C156246 | 01 | CA | STATE MEDICAL LICENSE | OTHER | FI7912810 | 01 | CA | FEDERAL DEA LICENSE | OTHER |