Provider Demographics
NPI:1437339249
Name:BRAZEAL, JUSTIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:R
Last Name:BRAZEAL
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 1:2803 EARL RUDDER FWY S
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6099
Mailing Address - Country:US
Mailing Address - Phone:979-731-8888
Mailing Address - Fax:
Practice Address - Street 1:2803 EARL RUDDER FWY S
Practice Address - Street 2:SUITE 103
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6099
Practice Address - Country:US
Practice Address - Phone:979-731-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6826207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307869301Medicaid
TX282074801Medicaid
TX307869301Medicaid
TXTXB131023Medicare PIN