Healthcare Provider Details

I. General information

NPI: 1386873453
Provider Name (Legal Business Name): JEREMY SEVILLE BRAGDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 03/15/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5268
APO AP
96368
US

IV. Provider business mailing address

18 MDG UNIT 5268
APO AP
96368-5217
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8823
  • Fax:
Mailing address:
  • Phone: 315-630-4780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0101228713
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: