Provider Demographics
NPI:1134110026
Name:BRAGONIER, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
Last Name:BRAGONIER
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 1:555 PETALUMA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4225
Mailing Address - Country:US
Mailing Address - Phone:707-823-7602
Mailing Address - Fax:707-823-7625
Practice Address - Street 1:555 PETALUMA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4225
Practice Address - Country:US
Practice Address - Phone:707-823-7602
Practice Address - Fax:707-823-7625
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75427207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G754270OtherPTAN
CA00G754270Medicaid
G13355Medicare UPIN
CAAQ181Medicare PIN
CA00G754270Medicaid
CA5616200001Medicare NSC