Provider Demographics
NPI:1386818516
Name:BREZAK, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:BREZAK
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 1:1304 FAWCETT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1900
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:
Practice Address - Street 1:1304 FAWCETT AVE STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1900
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603678332085B0100X
ORMD2051462085R0202X
WAMD603678332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA340866OtherLNI PROVIDER ID
WA2029135Medicaid
WA340865OtherLNI PROVIDER ID
WA1386818516Medicaid
WA340864OtherLNI PROVIDER ID
WA340867OtherLNI PROVIDER ID
WA340866OtherLNI PROVIDER ID
WA340865OtherLNI PROVIDER ID
WAG8941650Medicare PIN
WA2029135Medicaid
WA1386818516Medicaid