Provider Demographics
NPI:1407844301
Name:BREAUX, CHARLES W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:BREAUX
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:2643 PATTERSON RD
Mailing Address - Street 2:SUITE 603
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1936
Mailing Address - Country:US
Mailing Address - Phone:970-298-7440
Mailing Address - Fax:970-298-7459
Practice Address - Street 1:2643 PATTERSON RD
Practice Address - Street 2:SUITE 603
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1936
Practice Address - Country:US
Practice Address - Phone:970-298-7440
Practice Address - Fax:970-298-7459
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2012-07-18
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Provider Licenses
StateLicense IDTaxonomies
CO35211208600000X, 2086S0102X, 2086S0120X
AL11154208600000X, 2086S0102X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01352111Medicaid
NM10025031Medicaid
NV100504625Medicaid
COBRB1426OtherBCBS PROVIDER NUMBER
NM10025031Medicaid
E23474Medicare UPIN