Provider Demographics
NPI:1902115082
Name:MARK D BREITHAUPT PHD INC
Entity Type:Organization
Organization Name:MARK D BREITHAUPT PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BREITHAUPT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:408-320-2747
Mailing Address - Street 1:PO BOX 8396
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95155-8396
Mailing Address - Country:US
Mailing Address - Phone:408-320-2747
Mailing Address - Fax:408-320-2747
Practice Address - Street 1:1100 LINCOLN AVE STE 394
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125
Practice Address - Country:US
Practice Address - Phone:408-320-2747
Practice Address - Fax:408-320-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY499103T00000X, 103TA0400X, 103TC0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIHMSAOtherHMSA
HI03451701Medicaid
HIEM297AMedicare PIN
HI03451701Medicaid