MEDICARE: WILLIAM DAN BREAZEALE PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	1262122	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1538465901	OTHER	TX	NPI

General Provider Information

NPI Number	:	1144606518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM DAN BREAZEALE PT, DPT

Provider Business Mailing Address
First Line	:	11617 N CENTRAL EXPY
Second Line	:	SUITE 140
City	:	DALLAS
State	:	TX
Zip	:	75243-3800
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11617 N CENTRAL EXPY
Second Line	:	SUITE 140
City	:	DALLAS
State	:	TX
Zip	:	75243-3800
Country	:	US
Telephone Number	:	214-369-4123
Fax Number	:	214-369-2791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2015
Last Update Date	:	08/07/2015

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