Provider Demographics
NPI:1538124144
Name:BREEHL, MARC DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:DENNIS
Last Name:BREEHL
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 1:104 CALAIS CT
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5482
Mailing Address - Country:US
Mailing Address - Phone:318-347-8129
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:318-990-5710
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206991207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G1548OtherBCBSTX
TX175924301Medicaid
OK100065320AMedicaid
TX8D9475Medicare PIN
OK249724008Medicare PIN