Provider Demographics
NPI:1043414535
Name:BREKKEN, ALISSA (MD)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:BREKKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 E HIGHWAY 290 STE 240
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1144
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:10401 ANDERSON MILL RD STE 110B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-2579
Practice Address - Country:US
Practice Address - Phone:512-250-5571
Practice Address - Fax:512-331-0960
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096703208000000X
TXP7398208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX326111701Medicaid
TX326111702Medicaid
TX326111701Medicaid
TX316295YKXVMedicare PIN