Provider Demographics
NPI:1740500891
Name:BRAGIN, ILYA (MD)
Entity type:Individual
Prefix:DR
First Name:ILYA
Middle Name:
Last Name:BRAGIN
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 1:1616 BEST PL
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-3276
Mailing Address - Country:US
Mailing Address - Phone:484-526-5210
Mailing Address - Fax:484-526-5237
Practice Address - Street 1:1417 8TH AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-2256
Practice Address - Country:US
Practice Address - Phone:484-526-5210
Practice Address - Fax:484-526-5237
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4547842084P2900X, 2084N0400X
NY2748002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400143056Medicare UPIN