Provider Demographics
NPI:1053436337
Name:BREITHAUPT, MARK DOUGLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:BREITHAUPT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY 499103T00000X, 106H00000X, 103TC0700X
103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIA 3812-3OtherHMSA
HI03451701Medicaid
EM299ZMedicare PIN
HI0000TCBXVMedicare ID - Type Unspecified