Provider Demographics
NPI:1205943818
Name:BRISKIN, GARY B (DPM)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:B
Last Name:BRISKIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:310-828-2001
Practice Address - Street 1:2121 WILSHIRE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-828-0011
Practice Address - Fax:310-828-2001
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3141213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T11569Medicare UPIN
WE3141BMedicare ID - Type Unspecified