Provider Demographics
NPI:1912143025
Name:BRAGIN, ILANA NESSIE (MD)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:NESSIE
Last Name:BRAGIN
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 1:2315 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-4332
Mailing Address - Country:US
Mailing Address - Phone:646-962-2110
Mailing Address - Fax:
Practice Address - Street 1:2315 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-4332
Practice Address - Country:US
Practice Address - Phone:646-962-2110
Practice Address - Fax:646-962-0160
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X0097OtherBLUE CROSS BLUE SHIELD
TX209697601Medicaid
TX8X0097OtherBLUE CROSS BLUE SHIELD