1619049228 NPI number — DR. LARRY D BREAZEAL O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619049228 NPI number — DR. LARRY D BREAZEAL O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREAZEAL
Provider First Name:
LARRY
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1619049228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8220 N CORNERSTONE DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-8683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-659-9912
Provider Business Mailing Address Fax Number:
208-772-9382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8220 N CORNERSTONE DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835-8683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-772-5539
Provider Business Practice Location Address Fax Number:
208-772-9382
Provider Enumeration Date:
11/15/2006

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: 152W00000X , with the licence number:  OD00003957 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: ODP-1014 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2029890 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 805604301 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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