Provider Demographics
NPI:1396046454
Name:DIANA BREISTER GHOSH, M.D., INC.
Entity type:Organization
Organization Name:DIANA BREISTER GHOSH, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN & SURGEON/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BREISTER GHOSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-286-6446
Mailing Address - Street 1:6386 ALVARADO CT
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4905
Mailing Address - Country:US
Mailing Address - Phone:619-286-6446
Mailing Address - Fax:619-286-1618
Practice Address - Street 1:6386 ALVARADO CT
Practice Address - Street 2:SUITE 330
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4905
Practice Address - Country:US
Practice Address - Phone:619-286-6446
Practice Address - Fax:619-286-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55510208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A555101Medicaid
1629050943OtherNPI TYPE 1
CAA55510OtherMEDICAL LICENSE
CA00A555101Medicaid