Healthcare Provider Details

I. General information

NPI: 1396046454
Provider Name (Legal Business Name): DIANA BREISTER GHOSH, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6386 ALVARADO CT SUITE 330
SAN DIEGO CA
92120-4905
US

IV. Provider business mailing address

6386 ALVARADO CT SUITE 330
SAN DIEGO CA
92120-4905
US

V. Phone/Fax

Practice location:
  • Phone: 619-286-6446
  • Fax: 619-286-1618
Mailing address:
  • Phone: 619-286-6446
  • Fax: 619-286-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA55510
License Number StateCA

VIII. Authorized Official

Name: DR. DIANA MARIE BREISTER GHOSH
Title or Position: PHYSICIAN & SURGEON/PRESIDENT
Credential: M.D.
Phone: 619-286-6446