Provider Demographics
NPI:1942850367
Name:BRAGG, BRUCE GORDON
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GORDON
Last Name:BRAGG
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 1:2680 LORNA DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2844
Mailing Address - Country:US
Mailing Address - Phone:321-987-6014
Mailing Address - Fax:
Practice Address - Street 1:2680 LORNA DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2844
Practice Address - Country:US
Practice Address - Phone:321-987-6014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider