Provider Demographics
NPI:1922118280
Name:BRAUD, EDWARD L (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:BRAUD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:620 S GLENSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3206
Mailing Address - Country:US
Mailing Address - Phone:417-829-4246
Mailing Address - Fax:417-829-4332
Practice Address - Street 1:2055 S FREMONT AVE
Practice Address - Street 2:STE 1000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2206
Practice Address - Country:US
Practice Address - Phone:417-820-8099
Practice Address - Fax:417-820-8093
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-066106207RH0003X
WV24692207RX0202X
IDM-11165207RH0003X
MO2012003219207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL993010002Medicare PIN
D15230Medicare UPIN
P00740728Medicare PIN
MO000013268Medicare PIN
IL993010Medicare PIN