Provider Demographics
NPI:1447362462
Name:BRAHAM, ARLENE (MD)
Entity type:Individual
Prefix:
First Name:ARLENE
Middle Name:
Last Name:BRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 JACARANDA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4978
Mailing Address - Country:US
Mailing Address - Phone:760-956-2636
Mailing Address - Fax:
Practice Address - Street 1:12021 JACARANDA AVE STE 101
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-4978
Practice Address - Country:US
Practice Address - Phone:760-956-5174
Practice Address - Fax:760-948-2179
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66379208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G663790Medicaid
CA080039888OtherRAILROAD MEDICARE
CAF03381Medicare UPIN
CA00G663790Medicare ID - Type Unspecified