Provider Demographics
NPI:1194000554
Name:RICHARD S BRAGG MD PA
Entity Type:Organization
Organization Name:RICHARD S BRAGG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-805-8989
Mailing Address - Street 1:580 RINEHART RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1551
Mailing Address - Country:US
Mailing Address - Phone:407-805-8989
Mailing Address - Fax:
Practice Address - Street 1:580 RINEHART RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1551
Practice Address - Country:US
Practice Address - Phone:407-805-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD S BRAGG MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065139261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27228Medicare UPIN