Healthcare Provider Details

I. General information

NPI: 1154417178
Provider Name (Legal Business Name): EDWIN DEAN BRESHEARS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3527 W TRUMAN BLVD
JEFFERSON CITY MO
65109-5901
US

IV. Provider business mailing address

PO BOX 843966 SUITE B
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-8910
  • Fax: 573-884-1585
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR7213
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR7213
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: