Healthcare Provider Details

I. General information

NPI: 1710962642
Provider Name (Legal Business Name): MR. WILLES TODD BRAXTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 LEE RD KAEHLER MEMORIAL MEDICAL CLINIC
BUZZARDS BAY MA
02542-1313
US

IV. Provider business mailing address

PO BOX 1766
MASHPEE MA
02649-1766
US

V. Phone/Fax

Practice location:
  • Phone: 508-968-6578
  • Fax:
Mailing address:
  • Phone: 508-564-4814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberB1673135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: