Provider Demographics
NPI:1306821731
Name:BRAZER, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:BRAZER
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:790 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1755
Practice Address - Country:US
Practice Address - Phone:541-396-3111
Practice Address - Fax:541-396-5222
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080059412OtherRR MEDICARE PTAN NUMBER
OR011239Medicaid
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR930635514OtherGROUP TAX ID
ORMD07716OtherMEDICAL LICENSE OREGON
ORR0000WFBTVOtherGROUP MEDICARE PIN
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR930635514OtherGROUP TAX ID
ORC92274Medicare UPIN
ORCD8723OtherRR MEDICARE GROUP NUMBER