Provider Demographics
NPI:1497047708
Name:GUILLERMO E BRACHETTA MD PA
Entity Type:Organization
Organization Name:GUILLERMO E BRACHETTA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRACHETTA
Authorized Official - Suffix:
Authorized Official - Credentials:MDPA
Authorized Official - Phone:432-687-0181
Mailing Address - Street 1:2300 W MICHIGAN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-5855
Mailing Address - Country:US
Mailing Address - Phone:432-687-0181
Mailing Address - Fax:432-687-1003
Practice Address - Street 1:2300 W MICHIGAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5855
Practice Address - Country:US
Practice Address - Phone:432-687-0181
Practice Address - Fax:432-687-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5845208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034852601Medicaid
TX034852601Medicaid