Provider Demographics
NPI:1558336347
Name:BRAGG, RICHARD SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SCOTT
Last Name:BRAGG
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 1:580 RINEHART RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1551
Mailing Address - Country:US
Mailing Address - Phone:407-805-8989
Mailing Address - Fax:407-805-8833
Practice Address - Street 1:580 RINEHART RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1551
Practice Address - Country:US
Practice Address - Phone:407-805-8989
Practice Address - Fax:407-805-8833
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251635700Medicaid
FL251635700Medicaid
FL27228UMedicare PIN
FL080171275 RAILROADMedicare PIN