Healthcare Provider Details

I. General information

NPI: 1770522849
Provider Name (Legal Business Name): BROC LANE PRATT M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 71 STREET SUITE 620
MIAMI BEACH FL
33141-3089
US

IV. Provider business mailing address

PO BOX 32861
CHARLOTTE NC
28232-2861
US

V. Phone/Fax

Practice location:
  • Phone: 305-866-9951
  • Fax: 877-284-8933
Mailing address:
  • Phone: 704-446-6810
  • Fax: 877-284-8933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005-01398
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0090-00308
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number2005-01398
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2005-01398
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: