Provider Demographics
NPI:1548229297
Name:BREISCH, STUART (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:BREISCH
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:PO BOX 230760
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023-0760
Mailing Address - Country:US
Mailing Address - Phone:760-230-2251
Mailing Address - Fax:760-230-2253
Practice Address - Street 1:354 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5142
Practice Address - Country:US
Practice Address - Phone:760-230-2251
Practice Address - Fax:760-230-2253
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT164619-1205207PE0004X
CAG88386207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT06306Medicaid
UTD87705Medicare UPIN
UT005568403Medicare ID - Type Unspecified