Provider Demographics
NPI:1790098978
Name:THE DE BRITO PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:THE DE BRITO PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:DE BRITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:310-717-0069
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91102-0247
Mailing Address - Country:US
Mailing Address - Phone:626-405-4001
Mailing Address - Fax:818-301-7443
Practice Address - Street 1:751 N FAIR OAKS AVE
Practice Address - Street 2:301
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-3069
Practice Address - Country:US
Practice Address - Phone:626-405-4001
Practice Address - Fax:818-301-7443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66604103G00000X
CAG64523302F00000X
CAPSY26446305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADN405AMedicare PIN