Provider Demographics
NPI:1487649422
Name:BREAZEALE, EARL EDWARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:EDWARD
Last Name:BREAZEALE
Suffix:JR
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 1:6700 BAUM DR
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-7344
Mailing Address - Country:US
Mailing Address - Phone:865-584-5727
Mailing Address - Fax:865-450-9904
Practice Address - Street 1:2068 LAKESIDE CENTRE WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-6591
Practice Address - Country:US
Practice Address - Phone:865-342-0300
Practice Address - Fax:865-342-0301
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD27172174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF84980Medicare UPIN
TN3096391Medicare ID - Type Unspecified