Basic Information
| Provider Information | |||||||||
| NPI: | 1922194174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRESTWICH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | DUANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 E HERSEY ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975201359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264777 | ||||||||
| FaxNumber: | 5417086372 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 BOWER DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975013689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417343430 | ||||||||
| FaxNumber: | 5417343638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD203193 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | G64321 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BP1683095 | 01 | DEA | OTHER | 192219417 | 01 | CA | NPI | OTHER | 500790439 | 05 | OR | MEDICAID |