Provider Demographics
NPI:1073553400
Name:BREITBART, GARY B (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:B
Last Name:BREITBART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1511 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-5516
Mailing Address - Country:US
Mailing Address - Phone:908-561-9500
Mailing Address - Fax:908-561-7162
Practice Address - Street 1:1511 PARK AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-5516
Practice Address - Country:US
Practice Address - Phone:908-561-9500
Practice Address - Fax:908-561-7162
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA039937002086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1028839OtherCIGNA
NJ1340660OtherUNITED HEALTHCARE
NJ0280166000OtherAMERIHEALTH
NJ2292111OtherAETNA
NJES137OtherOXFORD
NJ0280166000OtherAMERIHEALTH
NJ1028839OtherCIGNA
NJC62902Medicare UPIN