Healthcare Provider Details

I. General information

NPI: 1053383372
Provider Name (Legal Business Name): FRED B BRACKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 WEBER RD
CORPUS CHRISTI TX
78411-3603
US

IV. Provider business mailing address

4234 WEBER RD
CORPUS CHRISTI TX
78411-3603
US

V. Phone/Fax

Practice location:
  • Phone: 361-883-3831
  • Fax: 361-887-0146
Mailing address:
  • Phone: 361-883-3831
  • Fax: 361-887-0146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberE7836
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: