Healthcare Provider Details

I. General information

NPI: 1871804187
Provider Name (Legal Business Name): EDWIN E BREITENBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

2601 AUGUSTA
TUSTIN CA
92782-1201
US

IV. Provider business mailing address

2601 AUGUSTA
TUSTIN CA
92782-1201
US

V. Phone/Fax

Practice location:
  • Phone: 714-730-0087
  • Fax:
Mailing address:
  • Phone: 714-730-0087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberGFE16157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: