Provider Demographics
NPI:1336708650
Name:BREITENBACH, TORI (DPM)
Entity Type:Individual
Prefix:
First Name:TORI
Middle Name:
Last Name:BREITENBACH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CLINT MOORE RD STE 18
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2768
Mailing Address - Country:US
Mailing Address - Phone:561-995-0229
Mailing Address - Fax:561-288-9045
Practice Address - Street 1:1601 CLINT MOORE RD STE 18
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2768
Practice Address - Country:US
Practice Address - Phone:561-995-0229
Practice Address - Fax:561-288-9045
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPO4508213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
5132635784OtherSTUDENT SCHOOL IDENTIFICATION NUMBER