Provider Demographics
NPI:1033450622
Name:BRAAKSMA, BRYCE JAHNOTHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:JAHNOTHAN
Last Name:BRAAKSMA
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 1:4815 LIBERTY AVE
Mailing Address - Street 2:STE 250-252
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:708-747-4000
Mailing Address - Fax:
Practice Address - Street 1:4815 LIBERTY AVE
Practice Address - Street 2:STE 250-252
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224
Practice Address - Country:US
Practice Address - Phone:708-747-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS019395207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program