Provider Demographics
NPI:1881641116
Name:BRATHWAITE, CORYSE V (MD)
Entity type:Individual
Prefix:DR
First Name:CORYSE
Middle Name:V
Last Name:BRATHWAITE
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:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6469
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2001 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3280
Practice Address - Country:US
Practice Address - Phone:443-481-1000
Practice Address - Fax:443-481-6933
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD46239174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5769117OtherAETNA PPO
MD590811600Medicaid
250AAA53270803OtherCAREFIRST MD
55880010OtherCAREFIRST DC
116546OtherKAISER
6801338OtherAETNA HMO
5769117OtherAETNA PPO
250AAA53270803OtherCAREFIRST MD
135498Y5ZMedicare PIN