Healthcare Provider Details

I. General information

NPI: 1164430856
Provider Name (Legal Business Name): GWYNNE A BRAGDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 VALLEY RD
MIDDLETOWN RI
02842-5236
US

IV. Provider business mailing address

PO BOX 1119
PROVIDENCE RI
02901-1119
US

V. Phone/Fax

Practice location:
  • Phone: 401-380-1188
  • Fax:
Mailing address:
  • Phone: 401-443-4150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD434563
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD12438
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberMD12438
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberMD434563
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: