Provider Demographics
NPI:1649278466
Name:BRAGG, LARRY MARK (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:MARK
Last Name:BRAGG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 N GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-3548
Mailing Address - Country:US
Mailing Address - Phone:254-918-6839
Mailing Address - Fax:254-968-7979
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:254-918-6839
Practice Address - Fax:254-968-7979
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6247208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134488908Medicaid
TXC13701Medicare UPIN
TX8D1798Medicare PIN