Provider Demographics
NPI:1801892146
Name:BREAZEALE, RICHARD I (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:I
Last Name:BREAZEALE
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 1:320 PROSPERITY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4709
Mailing Address - Country:US
Mailing Address - Phone:423-756-1512
Mailing Address - Fax:423-756-1004
Practice Address - Street 1:1605 WILLIAMS RD
Practice Address - Street 2:STE 201
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4934
Practice Address - Country:US
Practice Address - Phone:423-756-1512
Practice Address - Fax:423-756-1004
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56089207WX0107X
TN31597207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000860318CMedicaid
AL009937405Medicaid
TN3841514Medicaid
GA000860318EMedicaid
GA000860318CMedicaid
AL009937405Medicaid
GA000860318EMedicaid
TN3841514Medicaid
GA18BDGLTMedicare PIN