Provider Demographics
NPI:1093723793
Name:BRAZLEY, LARRY R (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:BRAZLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 E 86TH AVE
Mailing Address - Street 2:PO BOX 10645
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6382
Mailing Address - Country:US
Mailing Address - Phone:219-769-1670
Mailing Address - Fax:219-738-6714
Practice Address - Street 1:255 E 90TH DR
Practice Address - Street 2:W1
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8144
Practice Address - Country:US
Practice Address - Phone:219-791-0248
Practice Address - Fax:219-791-0251
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2011-06-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01032396207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100169080Medicaid
INC25239Medicare UPIN
IN148360Medicare PIN