Provider Demographics
NPI:1649278417
Name:BRACE, JOHN M (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:BRACE
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 1:2334 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3440
Mailing Address - Country:US
Mailing Address - Phone:440-992-0846
Mailing Address - Fax:440-992-7879
Practice Address - Street 1:2334 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3440
Practice Address - Country:US
Practice Address - Phone:440-992-0846
Practice Address - Fax:440-992-7879
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2010-07-27
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
OH1908207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE00596Medicare UPIN