Healthcare Provider Details

I. General information

NPI: 1437460359
Provider Name (Legal Business Name): ANDREW BREITHAUPT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MED PLZ SUITE 450
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

200 MED PLZ SUITE 450
LOS ANGELES CA
90095-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-6911
  • Fax:
Mailing address:
  • Phone: 310-825-6911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA118094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: