Basic Information
| Provider Information | |||||||||
| NPI: | 1861452328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAUN | ||||||||
| FirstName: | DEREK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 708850 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840708850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668692395 | ||||||||
| FaxNumber: | 8013529502 | ||||||||
| Practice Location | |||||||||
| Address1: | 6644 E BAYWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809814391 | ||||||||
| FaxNumber: | 4809814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25922 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | AZ0753310 | 01 | AZ | BC/BS OF AZ | OTHER | 8079511 | 05 | ID | MEDICAID | B6226 | 01 | ID | BCBS-NAMPA | OTHER | 462284 | 05 | AZ | MEDICAID | 77171 | 01 | ID | BCBS-CALDWELL | OTHER |