Provider Demographics
NPI:1982672069
Name:BRECKENRIDGE, JEFFREY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:BRECKENRIDGE
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 1:925 S NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-1874
Mailing Address - Country:US
Mailing Address - Phone:765-664-7492
Mailing Address - Fax:765-664-4356
Practice Address - Street 1:925 S NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-1874
Practice Address - Country:US
Practice Address - Phone:765-664-7492
Practice Address - Fax:765-664-4356
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045525A207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000033416OtherMPLAN
IN000000382235OtherANTHEM
MI104924162Medicaid
OH2619983Medicaid
IN200112530Medicaid
MI104924162Medicaid
ING43460Medicare UPIN
OH2619983Medicaid