Provider Demographics
NPI:1003865239
Name:BRAGG, JACK (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BRAGG
Suffix:
Gender:M
Credentials:DO
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 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:101 S FAIRVIEW ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-884-7600
Practice Address - Fax:573-884-8200
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5C31207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2900567OtherUNITED HEALTHCARE
MO241716018Medicaid
MO141665OtherHEALTHLINK
MO10904OtherBLUE CHOICE
MO10904OtherBLUE SHIELD
MO241716018Medicaid
MO018011879Medicare PIN
MO10904OtherBLUE SHIELD
E42717Medicare UPIN
MOP00433362Medicare PIN