Healthcare Provider Details

I. General information

NPI: 1790891885
Provider Name (Legal Business Name): THOMAS A BRAGG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SILVA LN SUITE A
MOBERLY MO
65270-3600
US

IV. Provider business mailing address

2100 SILVA LN SUITE A
MOBERLY MO
65270-3600
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-7201
  • Fax: 660-263-2260
Mailing address:
  • Phone: 660-263-7201
  • Fax: 660-263-2260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR8695
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: