Provider Demographics
NPI:1033105309
Name:HILLERMAN, BRAXTON L (MD)
Entity Type:Individual
Prefix:
First Name:BRAXTON
Middle Name:L
Last Name:HILLERMAN
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 1:826 WASHINGTON ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4063
Mailing Address - Country:US
Mailing Address - Phone:315-788-1751
Mailing Address - Fax:315-788-9021
Practice Address - Street 1:826 WASHINGTON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4063
Practice Address - Country:US
Practice Address - Phone:315-788-1751
Practice Address - Fax:315-788-9021
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161338207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00878313Medicaid
NY00878313Medicaid
B81179Medicare UPIN