Basic Information
| Provider Information | |||||||||
| NPI: | 1386818516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREZAK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Practice Location | |||||||||
| Address1: | 19020 33RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 60367833 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | MD205146 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60367833 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 340865 | 01 | WA | LNI PROVIDER ID | OTHER | 2029135 | 05 | WA | MEDICAID | 340866 | 01 | WA | LNI PROVIDER ID | OTHER | 340864 | 01 | WA | LNI PROVIDER ID | OTHER | 1386818516 | 05 | WA | MEDICAID | 340867 | 01 | WA | LNI PROVIDER ID | OTHER |