Provider Demographics
NPI:1659335115
Name:BRAGG, CORDELL (MD)
Entity Type:Individual
Prefix:DR
First Name:CORDELL
Middle Name:
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 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5019
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-279-1660
Practice Address - Street 1:915 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6614
Practice Address - Country:US
Practice Address - Phone:229-228-2000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26463207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA21713OtherBCBS
GAAB2740668OtherDEA
GAAB2740668OtherDEA
GA05BPBKNMedicare ID - Type Unspecified