Provider Demographics
NPI:1821178005
Name:BRACCIA, DOMENICK (DO)
Entity Type:Individual
Prefix:DR
First Name:DOMENICK
Middle Name:
Last Name:BRACCIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034
Mailing Address - Country:US
Mailing Address - Phone:267-419-7710
Mailing Address - Fax:
Practice Address - Street 1:1035 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3103
Practice Address - Country:US
Practice Address - Phone:267-419-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S006737L207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012371310008Medicaid
PA648589Medicare ID - Type Unspecified
E70526Medicare UPIN