Provider Demographics
NPI:1972785640
Name:LARRY BRAGG MD PA
Entity Type:Organization
Organization Name:LARRY BRAGG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:254-965-2310
Mailing Address - Street 1:PO BOX 1698
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-0017
Mailing Address - Country:US
Mailing Address - Phone:254-965-2310
Mailing Address - Fax:
Practice Address - Street 1:561 N GRAHAM ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3548
Practice Address - Country:US
Practice Address - Phone:254-965-2310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6247208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00212YMedicare PIN