Provider Demographics
NPI:1922357003
Name:BREEN, ETHAN JEREMY (DO)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:JEREMY
Last Name:BREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3408
Mailing Address - Country:US
Mailing Address - Phone:805-489-2205
Mailing Address - Fax:
Practice Address - Street 1:901 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3408
Practice Address - Country:US
Practice Address - Phone:805-489-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13057207Q00000X
NY266939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine