Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 27434 | MS |
NPI | 1023409422 |
---|---|
Provider Name | Dr. Mark Braswell |
First Address | Scott Afb, IL 62225-5250 |
Second Address | Scott Afb, IL 62225-5250 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2015 |
Last Update Date | 30/07/2020 |