Provider Demographics
NPI:1417032376
Name:BRISKIN, JONATHAN GARTH (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GARTH
Last Name:BRISKIN
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 1:101 S SAN MATEO DR
Mailing Address - Street 2:STE 213
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3843
Mailing Address - Country:US
Mailing Address - Phone:650-373-0170
Mailing Address - Fax:650-347-8966
Practice Address - Street 1:101 S SAN MATEO DR
Practice Address - Street 2:STE 213
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3843
Practice Address - Country:US
Practice Address - Phone:650-373-0170
Practice Address - Fax:650-347-8966
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31838207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G318381Medicaid
CA00G318380Medicare ID - Type UnspecifiedMEDICARE
CA00G318381Medicaid