Provider Demographics
NPI:1366454662
Name:BRECKENRIDGE, CHARLES WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:BRECKENRIDGE
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 1:5917 CROSSTOWN EXPRESSWAY SH 286
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78417
Mailing Address - Country:US
Mailing Address - Phone:361-854-0811
Mailing Address - Fax:361-806-5040
Practice Address - Street 1:5917 CROSSTOWN EXPRESSWAY SH 286
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78417
Practice Address - Country:US
Practice Address - Phone:361-854-0811
Practice Address - Fax:361-806-5040
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8212207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1106783-02Medicaid
TX1106783-02Medicaid