Provider Demographics
NPI:1285661736
Name:BRAGG, TRACI L (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:L
Last Name:BRAGG
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 44004
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4004
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-940-1490
Practice Address - Street 1:559 W TWINCOURT TRL UNIT 601
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8805
Practice Address - Country:US
Practice Address - Phone:904-940-1441
Practice Address - Fax:904-940-1490
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01113744OtherRR MEDICARE
FL274033800Medicaid
FL168054Medicare PIN
FLP01113744OtherRR MEDICARE
FL16805YMedicare PIN
FL202152094OtherTRICARE
FL202152094OtherCIGNA
FLI44592Medicare UPIN
FLK8815Medicare ID - Type Unspecified