Provider Demographics
NPI:1346321528
Name:BREAZEALE, PAUL QUENTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:QUENTIN
Last Name:BREAZEALE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 S CAPITAL OF TEXAS HWY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6579
Mailing Address - Country:US
Mailing Address - Phone:512-328-3881
Mailing Address - Fax:512-328-3882
Practice Address - Street 1:1515 S CAPITAL OF TEXAS HWY
Practice Address - Street 2:SUITE 220
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-6579
Practice Address - Country:US
Practice Address - Phone:512-328-3881
Practice Address - Fax:512-328-3882
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5530111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX74-2584816OtherFEDERAL TAX ID#
TX603299Medicare ID - Type Unspecified
TXU11939Medicare UPIN