Healthcare Provider Details

I. General information

NPI: 1568683076
Provider Name (Legal Business Name): PHILIP MICHAEL BRETSKY MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST SUITE 230
SANTA MONICA CA
90404-2050
US

IV. Provider business mailing address

1301 20TH ST SUITE 230
SANTA MONICA CA
90404-2050
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-4411
  • Fax: 310-828-2411
Mailing address:
  • Phone: 310-828-4411
  • Fax: 310-828-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA99447
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: