Provider Demographics
NPI:1164430856
Name:BRAGDON, GWYNNE A (MD)
Entity Type:Individual
Prefix:DR
First Name:GWYNNE
Middle Name:A
Last Name:BRAGDON
Suffix:
Gender:F
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:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:401-443-4150
Mailing Address - Fax:
Practice Address - Street 1:345 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5236
Practice Address - Country:US
Practice Address - Phone:401-380-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434563207X00000X, 207XS0106X
RIMD12438207XS0106X, 207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program