Provider Demographics
NPI:1053484873
Name:BRADEN, DONALD RAY (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:RAY
Last Name:BRADEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 REEVES AVE
Mailing Address - Street 2:STE B
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2162
Mailing Address - Country:US
Mailing Address - Phone:330-364-4461
Mailing Address - Fax:
Practice Address - Street 1:420 REEVES AVE
Practice Address - Street 2:STE B
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2162
Practice Address - Country:US
Practice Address - Phone:330-364-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0302970Medicaid
OH000000128389OtherANTHEM INSURANCE
C00965Medicare UPIN
OH0302970Medicaid