Provider Demographics
NPI:1386680221
Name:BRECKENRIDGE, RICHARD DALE (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DALE
Last Name:BRECKENRIDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:KEOSAUQUA
Mailing Address - State:IA
Mailing Address - Zip Code:52565-1164
Mailing Address - Country:US
Mailing Address - Phone:319-293-3171
Mailing Address - Fax:319-293-3473
Practice Address - Street 1:304 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:KEOSAUQUA
Practice Address - State:IA
Practice Address - Zip Code:52565-1164
Practice Address - Country:US
Practice Address - Phone:319-293-3171
Practice Address - Fax:319-293-3473
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA54335Medicare ID - Type Unspecified
IAA00811Medicare UPIN