Basic Information
| Provider Information | |||||||||
| NPI: | 1972591865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESMOND | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 S PALISADE DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934548902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059252521 | ||||||||
| FaxNumber: | 8059258721 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 S PALISADE DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934548902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059252521 | ||||||||
| FaxNumber: | 8059258721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 01/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A42662 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A426620 | 01 | CA | BLUESHIELD | OTHER |