Provider Demographics
NPI:1194795062
Name:BREAZEALE, NATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:BREAZEALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W 38TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1130
Mailing Address - Country:US
Mailing Address - Phone:512-450-1300
Mailing Address - Fax:512-450-1339
Practice Address - Street 1:900 W 38TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1130
Practice Address - Country:US
Practice Address - Phone:512-450-1300
Practice Address - Fax:512-450-1339
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1500207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102491102Medicaid
TX1278600001OtherMEDICARE SUPPLIER NUMBER
TX87172NMedicare ID - Type UnspecifiedMEDICARE
TXG45996Medicare UPIN
TX102491102Medicaid