Provider Demographics
NPI:1821283441
Name:BRAD A. BRAZEAL MD PA
Entity Type:Organization
Organization Name:BRAD A. BRAZEAL MD PA
Other - Org Name:BRAD A. BRAZEAL MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SELF/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAZEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-723-1940
Mailing Address - Street 1:300 WILLOW CREEK PKWY
Mailing Address - Street 2:STE 210
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-4421
Mailing Address - Country:US
Mailing Address - Phone:903-723-1940
Mailing Address - Fax:903-723-8307
Practice Address - Street 1:300 WILLOW CREEK PKWY
Practice Address - Street 2:STE 210
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4421
Practice Address - Country:US
Practice Address - Phone:903-723-1940
Practice Address - Fax:903-723-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX505092084P0800X, 2084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166535801Medicaid
TX124200005Medicaid