Healthcare Provider Details

I. General information

NPI: 1427230291
Provider Name (Legal Business Name): RAY M BRAQUET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 SOUTH HAWTHORNE ROAD
WINSTON SALEM NC
27103
US

IV. Provider business mailing address

1806 SOUTH HAWTHORNE ROAD
WINSTON SALEM NC
27103
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3632
  • Fax: 336-768-4473
Mailing address:
  • Phone: 336-768-3632
  • Fax: 336-768-4473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2008-00572
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: