Provider Demographics
NPI:1770522849
Name:PRATT, BROC LANE (MD)
Entity type:Individual
Prefix:DR
First Name:BROC
Middle Name:LANE
Last Name:PRATT
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:PO BOX 32861
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28232-2861
Mailing Address - Country:US
Mailing Address - Phone:704-446-6810
Mailing Address - Fax:877-284-8933
Practice Address - Street 1:300 71 STREET
Practice Address - Street 2:SUITE 620
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-3089
Practice Address - Country:US
Practice Address - Phone:305-866-9951
Practice Address - Fax:877-284-8933
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01398207Q00000X, 2082S0099X, 2086S0122X
NC0090-00308208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901841Medicaid
NC140KCOtherNCBCBS
SCN98005Medicaid
NC2052289CMedicare PIN
NC5901841Medicaid
NC2052289Medicare PIN
NC140KCOtherNCBCBS
I53884Medicare UPIN