Provider Demographics
NPI:1265401673
Name:BREIDEL, RANDY SCOTT (SUB IDC)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:SCOTT
Last Name:BREIDEL
Suffix:
Gender:M
Credentials:SUB IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 DWYER RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6924
Mailing Address - Country:US
Mailing Address - Phone:757-689-8742
Mailing Address - Fax:
Practice Address - Street 1:DAM NECK ANNEX
Practice Address - Street 2:1885 TERRIER AVE STE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23461-2298
Practice Address - Country:US
Practice Address - Phone:757-314-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman