Provider Demographics
NPI:1578736328
Name:CARTER, BRAZELL H (MD)
Entity Type:Individual
Prefix:
First Name:BRAZELL
Middle Name:H
Last Name:CARTER
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 1:2600 MACDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1826
Mailing Address - Country:US
Mailing Address - Phone:510-236-8484
Mailing Address - Fax:510-235-8650
Practice Address - Street 1:2600 MACDONALD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1826
Practice Address - Country:US
Practice Address - Phone:510-236-8484
Practice Address - Fax:510-235-8650
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA030396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26096Medicare UPIN