Basic Information
| Provider Information | |||||||||
| NPI: | 1487117420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRACAMONTE BARAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | HAENDEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRACAMONTE | ||||||||
| OtherFirstName: | WILLIAM | ||||||||
| OtherMiddleName: | H | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD, PHD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4214 ANDREWS HWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797034817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326866605 | ||||||||
| FaxNumber: | 4326822284 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 ROSALIND REDFERN GROVER PKWY | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797015846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4322211111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2019 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10068151 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | T2564 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | BP10068151 | 01 | TX | PIT CERT | OTHER |