Provider Demographics
NPI:1467450338
Name:BRAINARD, ROGER C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:C
Last Name:BRAINARD
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 1:3006 W AZEELE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3139
Mailing Address - Country:US
Mailing Address - Phone:813-874-3006
Mailing Address - Fax:813-876-6258
Practice Address - Street 1:3006 W AZEELE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3139
Practice Address - Country:US
Practice Address - Phone:813-874-3006
Practice Address - Fax:813-876-6258
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30199Medicare PIN
FLD85504Medicare UPIN