Provider Demographics
NPI:1518937697
Name:BRAGG, JEFFREY W (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:BRAGG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 NORTH WABASH
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-662-4133
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1391 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1913
Practice Address - Country:US
Practice Address - Phone:765-662-2534
Practice Address - Fax:765-671-7793
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100260500Medicaid
IN000000661496OtherANTHEM
INM400022128Medicare PIN
IN000000661496OtherANTHEM