Provider Demographics
NPI:1073522595
Name:BRADEN, TERESA KAY (DO)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:KAY
Last Name:BRADEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:KAY
Other - Last Name:O'DOWD/WIMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:311 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2705
Mailing Address - Country:US
Mailing Address - Phone:719-595-7585
Mailing Address - Fax:719-595-7589
Practice Address - Street 1:311 W 14TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2705
Practice Address - Country:US
Practice Address - Phone:719-595-7585
Practice Address - Fax:719-595-7589
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47646207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50627864Medicaid
COP01158993OtherRAILROAD MEDICARE
CO50627864Medicaid