Basic Information
| Provider Information | |||||||||
| NPI: | 1912916008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIXEY | ||||||||
| FirstName: | CLARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4097 CAMINITO TERVISO | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921221991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102185264 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4094 4TH AVE., STE. 200, MAIL CODE: 0834 | ||||||||
| Address2: | DEPT. OF RADIOLOGY BUSINESS OFFICE, UCSD | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195437636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101236649 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | C54415 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.