Provider Demographics
NPI:1619049228
Name:BREAZEAL, LARRY D (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:BREAZEAL
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 N CORNERSTONE DR STE A
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8683
Mailing Address - Country:US
Mailing Address - Phone:208-659-9912
Mailing Address - Fax:208-772-9382
Practice Address - Street 1:8220 N CORNERSTONE DR STE A
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8683
Practice Address - Country:US
Practice Address - Phone:208-772-5539
Practice Address - Fax:208-772-9382
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003957152W00000X
IDODP-1014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029890Medicaid
ID805604301Medicaid
ID805604301Medicaid
WA2029890Medicaid