Provider Demographics
NPI:1619051414
Name:BRAGG, LARRY E (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:E
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:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68848-2505
Mailing Address - Country:US
Mailing Address - Phone:308-865-2230
Mailing Address - Fax:308-238-2254
Practice Address - Street 1:3515 30TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2298
Practice Address - Country:US
Practice Address - Phone:308-865-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17428208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00403OtherBCBS
NE47064194502Medicaid
D17297Medicare UPIN
00403OtherBCBS