Provider Demographics
NPI:1770557753
Name:BRACKEN, ROBERTA SAMELSON (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:SAMELSON
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 COURTHOUSE DRIVE NE
Mailing Address - Street 2:P O BOX 9
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422
Mailing Address - Country:US
Mailing Address - Phone:910-253-2250
Mailing Address - Fax:910-253-2370
Practice Address - Street 1:25 COURTHOUSE DR NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422
Practice Address - Country:US
Practice Address - Phone:910-253-2250
Practice Address - Fax:910-253-2370
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35280207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8917621Medicaid
NC1770557753Medicaid
NC1770557753Medicaid
E89434Medicare UPIN
NC8917621Medicaid