Provider Demographics
NPI:1437416617
Name:BREAUX, JACOB LEE (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LEE
Last Name:BREAUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1211 COOLIDGE BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2636
Mailing Address - Country:US
Mailing Address - Phone:337-232-6697
Mailing Address - Fax:337-232-6605
Practice Address - Street 1:1211 COOLIDGE BLVD STE 303
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-232-6697
Practice Address - Fax:337-232-6605
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207307207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty