MEDICARE: DR. RICHARD I BREAZEALE M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207WX0107X	Retina Specialist (Ophthalmology) Physician	56089	GA
2	207WX0107X	Retina Specialist (Ophthalmology) Physician	31597	TN

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1801892146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD I BREAZEALE M.D.

Provider Business Mailing Address
First Line	:	320 PROSPERITY DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37923-4709
Country	:	US
Telephone Number	:	423-756-1512
Fax Number	:	423-756-1004

Provider Business Practice Location Address
First Line	:	1605 WILLIAMS RD
Second Line	:	STE 201
City	:	HIXSON
State	:	TN
Zip	:	37343-4934
Country	:	US
Telephone Number	:	423-756-1512
Fax Number	:	423-756-1004

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	12/03/2020

1605 WILLIAMS RD , STE 201
HIXSON, TN
37343-4934

Practice Phone: 423-756-1002
Practice Fax: 423-756-1004