Provider Demographics
NPI:1811553274
Name:BAEZA BREINBAUER, PABLO ANDRES
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:ANDRES
Last Name:BAEZA BREINBAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-6200
Mailing Address - Fax:510-535-2167
Practice Address - Street 1:1501 FRUITVALE AVE APT 2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2322
Practice Address - Country:US
Practice Address - Phone:510-535-6200
Practice Address - Fax:510-535-4167
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1001541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29799ZOtherPART B MEDICARE
CAFHC80040FMedicaid
CA05-1063OtherPART A MEDICARE