Provider Demographics
NPI:1811931306
Name:BRAULT, ANDREA MARGARETTE (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARGARETTE
Last Name:BRAULT
Suffix:
Gender:F
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:POST OFFICE BOX 662046
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-2046
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:3828 DELMAS TER
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2713
Practice Address - Country:US
Practice Address - Phone:310-202-4745
Practice Address - Fax:310-202-4168
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73405207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG73405OtherMEDICAL LICENSE
CA00G734050Medicaid
CA00G734050Medicaid
CAWG73405EMedicare PIN
CAF51029Medicare UPIN
CAWG73405GMedicare PIN
CAWG73405Medicare PIN