Provider Demographics
NPI:1275742181
Name:BREVING, JOEL (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:BREVING
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 1:2924 KNIGHT ST STE 410
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2413
Mailing Address - Country:US
Mailing Address - Phone:859-640-1727
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST STE 410
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2413
Practice Address - Country:US
Practice Address - Phone:859-640-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3080402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA017683OtherPMP
LA051144OtherCDS LICENSE
LAFB1068089OtherDEA
NY001AC0Z131Medicare PIN