Provider Demographics
NPI:1306031828
Name:STEPHEN D. BREDA MD FACS PC
Entity Type:Organization
Organization Name:STEPHEN D. BREDA MD FACS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BREDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS, PC
Authorized Official - Phone:203-371-5166
Mailing Address - Street 1:4695 MAIN ST 1
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1331
Mailing Address - Country:US
Mailing Address - Phone:203-371-5166
Mailing Address - Fax:203-374-7123
Practice Address - Street 1:4695 MAIN ST 1
Practice Address - Street 2:SUITE 1
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1331
Practice Address - Country:US
Practice Address - Phone:203-371-5166
Practice Address - Fax:203-374-7123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029401207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01361Medicare PIN