Basic Information
Provider Information | |||||||||
NPI: | 1699804138 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BREAU | ||||||||
FirstName: | RANDALL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4261 STOCKTON DRIVE SUITE LL100 | ||||||||
Address2: |   | ||||||||
City: | NORTH LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 72117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5019757456 | ||||||||
FaxNumber: | 5019781822 | ||||||||
Practice Location | |||||||||
Address1: | 9601 BAPTIST HEALTH DR STE 860 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722056375 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5019757455 | ||||||||
FaxNumber: | 5019753631 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2007 | ||||||||
LastUpdateDate: | 07/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | E1230 | AR | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207NS0135X | E1230 | AR | N |   | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207ND0101X | E1230 | AR | Y |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
ID | Type | State | Issuer | Description | 131705001 | 05 | AR |   | MEDICAID |