Healthcare Provider Details

I. General information

NPI: 1023647948
Provider Name (Legal Business Name): BRADEN HAROLD DANBURY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BRADEN HAROLD DAVIS

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 GRAND AVE
WAUKEGAN IL
60085-3312
US

IV. Provider business mailing address

2323 GRAND AVE
WAUKEGAN IL
60085-3312
US

V. Phone/Fax

Practice location:
  • Phone: 847-666-3494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036169129
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036169129
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: