Provider Demographics
NPI:1710962642
Name:BRAXTON, WILLES TODD
Entity Type:Individual
Prefix:MR
First Name:WILLES
Middle Name:TODD
Last Name:BRAXTON
Suffix:
Gender:M
Credentials:
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 1766
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-1766
Mailing Address - Country:US
Mailing Address - Phone:508-564-4814
Mailing Address - Fax:
Practice Address - Street 1:5201 LEE RD
Practice Address - Street 2:KAEHLER MEMORIAL MEDICAL CLINIC
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02542-1313
Practice Address - Country:US
Practice Address - Phone:508-968-6578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1673135171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider