Provider Demographics
NPI:1417155151
Name:BRAYFORD, MARK DANIEL (DO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DANIEL
Last Name:BRAYFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:48 TUNNEL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3875
Mailing Address - Country:US
Mailing Address - Phone:570-624-4777
Mailing Address - Fax:570-624-4778
Practice Address - Street 1:48 TUNNEL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3875
Practice Address - Country:US
Practice Address - Phone:570-624-4777
Practice Address - Fax:570-624-4778
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013357207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA122929JPUMedicare PIN