Provider Demographics
NPI:1053383372
Name:BRACKETT, FRED B (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:B
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-3603
Mailing Address - Country:US
Mailing Address - Phone:361-883-3831
Mailing Address - Fax:361-887-0146
Practice Address - Street 1:4234 WEBER RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-3603
Practice Address - Country:US
Practice Address - Phone:361-883-3831
Practice Address - Fax:361-887-0146
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7836208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114250703Medicaid
TXB21446Medicare UPIN
TX80W660Medicare ID - Type Unspecified