Provider Demographics
NPI:1053337840
Name:BREZICKI, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:BREZICKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 NE GATEWAY CT NE
Practice Address - Street 2:STE 202
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2414
Practice Address - Country:US
Practice Address - Phone:704-403-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29726207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053337840Medicaid
NC8918159Medicaid
NC1053337840Medicaid
NCNC6177CMedicare PIN
NCNC61770386Medicare PIN
NCNC6177BMedicare PIN
NC203629EMedicare PIN
NC203629DMedicare PIN
NC8918159Medicaid
NC203629FMedicare PIN
NCNC6177AMedicare PIN
NC203629GMedicare PIN