Provider Demographics
NPI:1629050943
Name:BREISTER, DIANA M (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:BREISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:BREISTER GHOSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2275 RIO BONITO WAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1685
Mailing Address - Country:US
Mailing Address - Phone:619-822-1667
Mailing Address - Fax:619-684-1730
Practice Address - Street 1:2275 RIO BONITO WAY
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1685
Practice Address - Country:US
Practice Address - Phone:619-822-1667
Practice Address - Fax:619-684-1730
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55510208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396046454OtherNPI TYPE 2
CA00A555101Medicaid
CAA55510OtherMEDICAL LICENSE
CA00A555101Medicaid