Provider Demographics
NPI:1881191393
Name:JACOB L BREAUX, MD, LLC
Entity Type:Organization
Organization Name:JACOB L BREAUX, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-804-2794
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:337-708-2794
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:70503-2636
Practice Address - Country:US
Practice Address - Phone:337-708-2794
Practice Address - Fax:337-232-6605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherTAX ID