Provider Demographics
NPI:1417969031
Name:BRACKEN, WILLIAM MARTIN (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARTIN
Last Name:BRACKEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4116
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:14365 HIGHWAY 16 W
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:MS
Practice Address - Zip Code:39328-7974
Practice Address - Country:US
Practice Address - Phone:601-743-4626
Practice Address - Fax:601-743-2133
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15288207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118406Medicaid
G43810Medicare UPIN
MS930003354Medicare Oscar/Certification