Provider Demographics
NPI:1811090111
Name:BRAGIN, STEPHEN D (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
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:PO BOX 3201
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91221-0201
Mailing Address - Country:US
Mailing Address - Phone:213-977-2000
Mailing Address - Fax:213-977-2030
Practice Address - Street 1:1225 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1901
Practice Address - Country:US
Practice Address - Phone:213-977-2000
Practice Address - Fax:213-977-2030
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30255208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G302550Medicaid
CA00G302550Medicaid
A71273Medicare UPIN