Healthcare Provider Details

I. General information

NPI: 1629050943
Provider Name (Legal Business Name): DIANA M BREISTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA BREISTER GHOSH

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 RIO BONITO WAY SUITE 220
SAN DIEGO CA
92108-1685
US

IV. Provider business mailing address

2275 RIO BONITO WAY SUITE 220
SAN DIEGO CA
92108-1685
US

V. Phone/Fax

Practice location:
  • Phone: 619-822-1667
  • Fax: 619-684-1730
Mailing address:
  • Phone: 619-822-1667
  • Fax: 619-684-1730

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:
Title or Position:
Credential:
Phone: