Provider Demographics
NPI:1598821597
Name:RICHARD S BRAGG MD PA
Entity Type:Organization
Organization Name:RICHARD S BRAGG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-805-8989
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
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
Practice Address - Country:US
Practice Address - Phone:407-805-8989
Practice Address - Fax:407-805-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8240Medicare PIN