Healthcare Provider Details

I. General information

NPI: 1790098978
Provider Name (Legal Business Name): THE DE BRITO PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N FAIR OAKS AVE 301
PASADENA CA
91103-3069
US

IV. Provider business mailing address

PO BOX 247
PASADENA CA
91102-0247
US

V. Phone/Fax

Practice location:
  • Phone: 626-405-4001
  • Fax: 818-301-7443
Mailing address:
  • Phone: 626-405-4001
  • Fax: 818-301-7443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberA66604
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberG64523
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberPSY26446
License Number StateCA

VIII. Authorized Official

Name: DR. DIRK DE BRITO
Title or Position: PRESIDENT
Credential: MD, MPH
Phone: 310-717-0069