Provider Demographics
NPI:1144809039
Name:BRASCH, VIVIAN JUDITH (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:JUDITH
Last Name:BRASCH
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 1:605 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3211
Mailing Address - Country:US
Mailing Address - Phone:352-796-9990
Mailing Address - Fax:352-796-2226
Practice Address - Street 1:605 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3211
Practice Address - Country:US
Practice Address - Phone:352-796-9990
Practice Address - Fax:352-796-2226
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME168848207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program