Healthcare Provider Details

I. General information

NPI: 1003865239
Provider Name (Legal Business Name): JACK DWAYNE BRAGG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-8445
  • Fax: 573-884-5318
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberR5C31
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: