Provider Demographics
NPI:1023097052
Name:BRETH, EVAN (DPM)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:BRETH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2352 RALPH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5515
Mailing Address - Country:US
Mailing Address - Phone:718-251-0200
Mailing Address - Fax:718-209-5697
Practice Address - Street 1:2352 RALPH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5515
Practice Address - Country:US
Practice Address - Phone:718-251-0200
Practice Address - Fax:718-209-5697
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005657213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02063578Medicaid
NYU80879Medicare UPIN
NY02063578Medicaid