Healthcare Provider Details

I. General information

NPI: 1487649422
Provider Name (Legal Business Name): EARL EDWARD BREAZEALE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2068 LAKESIDE CENTRE WAY
KNOXVILLE TN
37922-6591
US

IV. Provider business mailing address

6700 BAUM DR SUITE ONE
KNOXVILLE TN
37919-7344
US

V. Phone/Fax

Practice location:
  • Phone: 865-342-0300
  • Fax: 865-342-0301
Mailing address:
  • Phone: 865-584-5727
  • Fax: 865-450-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD27172
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: