Healthcare Provider Details

I. General information

NPI: 1649278417
Provider Name (Legal Business Name): JOHN M BRACE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/24/2006

III. Provider practice location address

2334 LAKE AVE
ASHTABULA OH
44004-3440
US

IV. Provider business mailing address

2334 LAKE AVE
ASHTABULA OH
44004-3440
US

V. Phone/Fax

Practice location:
  • Phone: 440-992-0846
  • Fax: 440-992-7879
Mailing address:
  • Phone: 440-992-0846
  • Fax: 440-992-7879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number1908
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: