Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | ME11805 | FL |
NPI | 1114081965 |
---|---|
Provider Name | Dr. Braxton William Price |
First Address | Lady Lake, FL 32159-2536 |
Second Address | Lady Lake, FL 32159-2536 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 14/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
049348101 | (05) | FL |
D54302 | (02) | FL |