Provider Demographics
NPI:1508876699
Name:BRACKMANN, DERALD E (MD)
Entity Type:Individual
Prefix:DR
First Name:DERALD
Middle Name:E
Last Name:BRACKMANN
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 1:2100 W 3RD ST STE 111
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1999
Mailing Address - Country:US
Mailing Address - Phone:213-483-9930
Mailing Address - Fax:213-483-0905
Practice Address - Street 1:2100 W 3RD ST STE 111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1999
Practice Address - Country:US
Practice Address - Phone:213-483-9930
Practice Address - Fax:213-483-0905
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11124207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G111240Medicaid
WG11124BMedicare PIN
A38229Medicare UPIN