Healthcare Provider Details

I. General information

NPI: 1417941907
Provider Name (Legal Business Name): JAMES W BREEDLOVE D P M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date: 03/25/2006
Reactivation Date: 04/13/2006

III. Provider practice location address

275 MARINA ST
MORRO BAY CA
93442-2244
US

IV. Provider business mailing address

275 MARINA ST
MORRO BAY CA
93442-2244
US

V. Phone/Fax

Practice location:
  • Phone: 805-543-3025
  • Fax: 805-543-2740
Mailing address:
  • Phone: 805-543-3025
  • Fax: 805-543-2740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE3976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: