Provider Demographics
NPI:1114081965
Name:PRICE, BRAXTON WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAXTON
Middle Name:WILLIAM
Last Name:PRICE
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 1:1411 MEADOW VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-2536
Mailing Address - Country:US
Mailing Address - Phone:352-350-2883
Mailing Address - Fax:
Practice Address - Street 1:1411 MEADOW VIEW WAY
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-2536
Practice Address - Country:US
Practice Address - Phone:352-350-2883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME11805207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049348101Medicaid
FLD54302Medicare UPIN
FL049348101Medicaid