Healthcare Provider Details

I. General information

NPI: 1770517740
Provider Name (Legal Business Name): PAUL A. BREAULT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 SUN CITY CENTER PLZ STE 103
SUN CITY CENTER FL
33573-5374
US

IV. Provider business mailing address

1647 SUN CITY CENTER PLZ STE 103
SUN CITY CENTER FL
33573-5374
US

V. Phone/Fax

Practice location:
  • Phone: 813-634-6344
  • Fax:
Mailing address:
  • Phone: 813-634-6344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3216
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC 3216
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: