Provider Demographics
NPI:1326209628
Name:EDWARD F. BREAUX MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD F. BREAUX MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:BREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-233-6665
Mailing Address - Street 1:1016 COOLIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2436
Mailing Address - Country:US
Mailing Address - Phone:337-233-6665
Mailing Address - Fax:337-233-0327
Practice Address - Street 1:1016 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2436
Practice Address - Country:US
Practice Address - Phone:337-233-6665
Practice Address - Fax:337-233-0327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016579208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1376957Medicaid
LA5DE20Medicare PIN
LA1376957Medicaid