=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649532078
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADAM PHILLIP BRECEDA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 12/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3537 S INTERSTATE 35 E STE 112
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76210-6868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-800-1920
-----------------------------------------------------
Fax | 866-741-2621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3537 S INTERSTATE 35 E STE 112
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76210-6868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-800-1920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | BP10044421
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 63789
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | S3495
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------