Provider Demographics
NPI:1386963999
Name:DREISBACH, JEREMIAH DANIEL (MD)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:DANIEL
Last Name:DREISBACH
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 1:67 TEMPE TRL
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-4203
Mailing Address - Country:US
Mailing Address - Phone:760-835-1663
Mailing Address - Fax:
Practice Address - Street 1:47647 CALEO BAY DR STE 210
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8858
Practice Address - Country:US
Practice Address - Phone:760-771-1000
Practice Address - Fax:760-771-9001
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124053207XX0005X
CAC159710207QS0010X
GA069576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA069576OtherGA LICENSE