Provider Demographics
NPI:1578737441
Name:BRUCE R. BRAGONIER, MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRUCE R. BRAGONIER, MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BRAGONIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-823-7602
Mailing Address - Street 1:555 PETALUMA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4224
Mailing Address - Country:US
Mailing Address - Phone:707-823-7602
Mailing Address - Fax:707-823-7625
Practice Address - Street 1:555 PETALUMA AVE
Practice Address - Street 2:STE B
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4224
Practice Address - Country:US
Practice Address - Phone:707-823-7602
Practice Address - Fax:707-823-7625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75427207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G754270Medicaid
CA6154150001Medicare NSC
CAG13355Medicare UPIN
CA00G754270Medicaid
CAAQ182Medicare PIN