1205062296 NPI number — DR. STEPHEN JOSEPH BREAUD DDS,MSD

Table of content: DR. STEPHEN JOSEPH BREAUD DDS,MSD (NPI 1205062296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205062296 NPI number — DR. STEPHEN JOSEPH BREAUD DDS,MSD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREAUD
Provider First Name:
STEPHEN
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS,MSD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205062296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4630 50TH ST
Provider Second Line Business Mailing Address:
STE 505
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79414-3521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-795-5503
Provider Business Mailing Address Fax Number:
806-795-1210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 50TH ST
Provider Second Line Business Practice Location Address:
STE 505
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79414-3521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-795-5503
Provider Business Practice Location Address Fax Number:
806-795-1210
Provider Enumeration Date:
06/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  11475 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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