Healthcare Provider Details

I. General information

NPI: 1447573332
Provider Name (Legal Business Name): JEFFREY A BRAISTED A.S.R.T.,R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

IV. Provider business mailing address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

V. Phone/Fax

Practice location:
  • Phone: 845-692-8780
  • Fax: 845-692-3439
Mailing address:
  • Phone: 845-692-8780
  • Fax: 845-692-3439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number465880
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: