Provider Demographics
NPI:1447305438
Name:HUBBARD, BRYAN DAVID (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-0304
Mailing Address - Country:US
Mailing Address - Phone:213-673-1478
Mailing Address - Fax:310-347-4318
Practice Address - Street 1:1513 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3070
Practice Address - Country:US
Practice Address - Phone:213-673-1478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG079530208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery