Provider Demographics
NPI:1699883785
Name:BREAZEALE, BRETTON HOWARD (MD)
Entity type:Individual
Prefix:MR
First Name:BRETTON
Middle Name:HOWARD
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:PO BOX 7326
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97602-0326
Mailing Address - Country:US
Mailing Address - Phone:541-205-3974
Mailing Address - Fax:541-205-5652
Practice Address - Street 1:2900 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-205-3974
Practice Address - Fax:541-205-5652
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD265552085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY204768Medicaid
OR213057Medicaid
I67455Medicare UPIN
OR213057Medicaid