Provider Demographics
NPI:1508041286
Name:BRAXTON, DEMETRIUS
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:BRAXTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 582
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20623-0582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9703 STARBOARD CT
Practice Address - Street 2:
Practice Address - City:CHELTENHAM
Practice Address - State:MD
Practice Address - Zip Code:20623-1357
Practice Address - Country:US
Practice Address - Phone:202-431-3880
Practice Address - Fax:301-782-9769
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter