1619167517 NPI number — MR. JASON A BREAUX MD

Table of content: MR. JASON A BREAUX MD (NPI 1619167517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619167517 NPI number — MR. JASON A BREAUX MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREAUX
Provider First Name:
JASON
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1619167517
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
457 HEYMANN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70503-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-237-5774
Provider Business Mailing Address Fax Number:
337-237-4940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
457 HEYMANN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-2616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-237-5774
Provider Business Practice Location Address Fax Number:
337-237-4940
Provider Enumeration Date:
07/26/2007

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: 2086X0206X , with the licence number:  MD.026385 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD.026385 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 26385 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: MD434211 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1058122 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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