Provider Demographics
NPI:1770517740
Name:BREAULT, PAUL A (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:BREAULT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 SUN CITY CENTER PLZ STE 103
Mailing Address - Street 2:
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-5374
Mailing Address - Country:US
Mailing Address - Phone:813-634-6344
Mailing Address - Fax:
Practice Address - Street 1:1647 SUN CITY CENTER PLZ STE 103
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5374
Practice Address - Country:US
Practice Address - Phone:813-634-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3216152W00000X
FLOPC 3216152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59-3632508OtherTAX-ID #