Provider Demographics
NPI:1083686463
Name:BREAZEALE, DANIEL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ROBERT
Last Name:BREAZEALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2615 LAKE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6693
Mailing Address - Country:US
Mailing Address - Phone:919-781-9555
Mailing Address - Fax:919-781-1070
Practice Address - Street 1:2615 LAKE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6693
Practice Address - Country:US
Practice Address - Phone:919-781-9555
Practice Address - Fax:919-781-1070
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0069960207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0329801 00Medicaid
MD0329801 00Medicaid