Provider Demographics
NPI:1063413177
Name:BREISBLATT, WARREN MARK (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:MARK
Last Name:BREISBLATT
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 1:2500 W UTOPIA RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4171
Mailing Address - Country:US
Mailing Address - Phone:602-214-6148
Mailing Address - Fax:602-214-6149
Practice Address - Street 1:9250 N. 3RD STREET
Practice Address - Street 2:SUITE 3010
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2425
Practice Address - Country:US
Practice Address - Phone:602-861-1168
Practice Address - Fax:602-861-1763
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24667207RC0000X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ370247Medicaid
AZZ69037Medicare PIN
B41649Medicare UPIN