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General NPI Number Information
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NPI Number | 1619049228
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Entity Type | Individual
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Provider Name | LARRY D BREAZEAL O.D.
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Gender | Male
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 03/17/2025
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Provider Practice Location Address
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Address Line | 8220 N CORNERSTONE DR STE A
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City | HAYDEN
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State | ID
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Zip | 83835-8683
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Country | US
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Telephone | 208-772-5539
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Fax | 208-772-9382
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Provider Business Mailing Address
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Address Line | 8220 N CORNERSTONE DR STE A
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City | HAYDEN
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State | ID
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Zip | 83835-8683
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Country | US
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Telephone | 208-659-9912
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Fax | 208-772-9382
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OD00003957
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-1014
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License Number State | ID
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