Provider Demographics
NPI:1083650741
Name:BREITWIESER, DAVID G (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:BREITWIESER
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9650 E WASHINGTON ST
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3032
Practice Address - Country:US
Practice Address - Phone:317-890-5500
Practice Address - Fax:317-890-5566
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01028551A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100330320Medicaid
IN080120537Medicare PIN
IN676070QMedicare PIN
IN264430GMedicare PIN
INE16298Medicare UPIN
IN100330320Medicaid