Provider Demographics
NPI:1619905924
Name:BRACE, JEFFREY REX (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:REX
Last Name:BRACE
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 1:2355 HIGHWAY 36 W STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3905
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:
Practice Address - Street 1:2355 HIGHWAY 36 W STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3905
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN445152085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1034029OtherPREFERRED ONE
MN588T5BROtherBCBS
MT0091681Medicaid
MN16-02032OtherMEDICA PRIMARY
MN1811611OtherARAZ
MN330412400Medicaid
MNP00253879OtherRAILROAD MEDICARE
IA0589325Medicaid
MN16-03496OtherMEDICA CHOICE
MNB592OtherCHAMPUS/TRIWEST
MNHP44290OtherHEALTHPARTNERS
MN17131OtherUCARE
WI34612300Medicaid
MT0091681Medicaid
MNH78042Medicare UPIN