MEDICARE: DR. JEFFREY IAN BRAGMAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY5659	CA

General Provider Information

NPI Number	:	1841276599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY IAN BRAGMAN PH.D.

Provider Business Mailing Address
First Line	:	412 CEDAR ST
Second Line	:
City	:	SAN CARLOS
State	:	CA
Zip	:	94070-2163
Country	:	US
Telephone Number	:	650-591-4331
Fax Number	:	650-591-4773

Provider Business Practice Location Address
First Line	:	974 RALSTON AVE
Second Line	:	SUITE 10
City	:	BELMONT
State	:	CA
Zip	:	94002-2252
Country	:	US
Telephone Number	:	800-353-2761
Fax Number	:	650-591-4773

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	07/08/2007

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