Basic Information
Provider Information | |||||||||
NPI: | 1144476995 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRAAKSMA | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6020 W PARKER RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750938172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9726085000 | ||||||||
FaxNumber: | 9726085068 | ||||||||
Practice Location | |||||||||
Address1: | 3025 N TARRANT PKWY STE 220 | ||||||||
Address2: |   | ||||||||
City: | FT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761778629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8178986688 | ||||||||
FaxNumber: | 8175628313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2008 | ||||||||
LastUpdateDate: | 11/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | S9661 | TX | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
ID | Type | State | Issuer | Description | S9661 | 01 | TX | TMB | OTHER |