Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 11154 | AL |
N | 208600000X | Surgeon | 11154 | AL |
N | 208200000X | Surgeon | 35211 | CO |
N | 208600000X | Surgeon | 35211 | CO |
N | 2086S0102X | Surgical Critical Care | 11154 | AL |
N | 2086S0102X | Surgical Critical Care | 35211 | CO |
N | 2086S0120X | Pediatric Surgery | 11154 | AL |
Y | 2086S0120X | Pediatric Surgery | 35211 | CO |
NPI | 1407844301 |
---|---|
Provider Name | Dr. Charles W Breaux JR. |
First Address | Grand Junction, CO 81506-1936 |
Second Address | Grand Junction, CO 81506-1936 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2005 |
Last Update Date | 18/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01352111 | (05) | CO |
10025031 | (05) | NM |
100504625 | (05) | NV |
BRB1426 | BCBS PROVIDER NUMBER (01) | CO |
E23474 | (02) |