Healthcare Provider Details

I. General information

NPI: 1730107509
Provider Name (Legal Business Name): RICHARD LEE BRAITHWAITE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 RIDGEWOOD AVE
HOLLY HILL FL
32117-2320
US

IV. Provider business mailing address

P.O. BOX 9671
DAYTONA BEACH FL
32120-9671
US

V. Phone/Fax

Practice location:
  • Phone: 386-676-7130
  • Fax: 386-676-7125
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME90496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: