Healthcare Provider Details

I. General information

NPI: 1578592218
Provider Name (Legal Business Name): MATTHEW R BRACKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E 76TH ST # 1D
NEW YORK NY
10021-2810
US

IV. Provider business mailing address

80 PARK AVE APT 12P
NEW YORK NY
10016-0282
US

V. Phone/Fax

Practice location:
  • Phone: 202-573-9091
  • Fax:
Mailing address:
  • Phone: 941-806-9381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number241144
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number228014
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: