Provider Demographics
NPI:1629417845
Name:BRAXTON, JOHN KEITH (DPT, PTA)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEITH
Last Name:BRAXTON
Suffix:
Gender:M
Credentials:DPT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17615 CYPRESS LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-4777
Mailing Address - Country:US
Mailing Address - Phone:832-563-1578
Mailing Address - Fax:
Practice Address - Street 1:17615 CYPRESS LAUREL ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-4777
Practice Address - Country:US
Practice Address - Phone:832-563-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2094020171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor