Provider Demographics
NPI:1467428458
Name:BRAUTIGAM, RICHARD G (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:BRAUTIGAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 E BROADWAY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4972
Mailing Address - Country:US
Mailing Address - Phone:509-928-1212
Mailing Address - Fax:509-924-5035
Practice Address - Street 1:12121 E BROADWAY AVE STE 1
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4972
Practice Address - Country:US
Practice Address - Phone:509-928-1212
Practice Address - Fax:509-924-5035
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000930152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2085405Medicaid
WADG8772OtherPTAN
WA410006929OtherRAILROAD MEDICARE
WADG8772OtherRAILROAD GROUP
WADG8772OtherPTAN
WAG319210300Medicare PIN
WADG8772OtherRAILROAD GROUP