Provider Demographics
NPI:1740211838
Name:BRETZ, PHILLIP DE EVANS (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:DE EVANS
Last Name:BRETZ
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 600534
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-0534
Mailing Address - Country:US
Mailing Address - Phone:800-775-6029
Mailing Address - Fax:619-220-0905
Practice Address - Street 1:35280 BOB HOPE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1753
Practice Address - Country:US
Practice Address - Phone:760-324-8323
Practice Address - Fax:760-324-8779
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32596174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A325960Medicaid
CA00A325960Medicare ID - Type Unspecified