Provider Demographics
NPI:1093739393
Name:BRETTHOLZ, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:BRETTHOLZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 E 30TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8366
Mailing Address - Country:US
Mailing Address - Phone:212-614-0039
Mailing Address - Fax:212-253-9631
Practice Address - Street 1:232 E 30TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8202
Practice Address - Country:US
Practice Address - Phone:212-889-5544
Practice Address - Fax:212-481-1089
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165247207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01683036Medicaid
NY01683036Medicaid
NY69D781Medicare PIN