1629050943 NPI number — DIANA M BREISTER M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629050943 NPI number — DIANA M BREISTER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREISTER
Provider First Name:
DIANA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BREISTER GHOSH
Provider Other First Name:
DIANA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629050943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2275 RIO BONITO WAY
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-1685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-822-1667
Provider Business Mailing Address Fax Number:
619-684-1730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2275 RIO BONITO WAY
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-1685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-822-1667
Provider Business Practice Location Address Fax Number:
619-684-1730
Provider Enumeration Date:
11/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  A55510 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1396046454 . This is a "NPI TYPE 2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00A555101 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: A55510 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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