Provider Demographics
NPI:1073838488
Name:TREADAWAY, BRENT LUCAS (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LUCAS
Last Name:TREADAWAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 CHEROKEE ROSE CIR
Mailing Address - Street 2:NONE
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7120
Mailing Address - Country:US
Mailing Address - Phone:512-784-0054
Mailing Address - Fax:
Practice Address - Street 1:2201 S CLEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4110
Practice Address - Country:US
Practice Address - Phone:254-526-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI5101018697207P00000X
TXQ0583207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program