Healthcare Provider Details

I. General information

NPI: 1962186726
Provider Name (Legal Business Name): BRAXTON HARRIS RIDER D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 AUDUBON PLAZA DR STE 320
LOUISVILLE KY
40217-1319
US

IV. Provider business mailing address

PO BOX 3276
EVANSVILLE IN
47731-3276
US

V. Phone/Fax

Practice location:
  • Phone: 502-893-1844
  • Fax: 502-634-3758
Mailing address:
  • Phone: 812-473-0181
  • Fax: 812-492-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License Number284367
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number284367
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number284367
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number284367
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number284367
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number284367
License Number StateKY
# 7
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number284367
License Number StateKY
# 8
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number284367
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: