Provider Demographics
NPI:1104146190
Name:BRADDOCK ACEVEDO, HEATHER (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BRADDOCK ACEVEDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 WAKE DR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4746
Mailing Address - Country:US
Mailing Address - Phone:919-556-4779
Mailing Address - Fax:919-556-5277
Practice Address - Street 1:1655 WAKE DR UNIT 101
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4746
Practice Address - Country:US
Practice Address - Phone:919-556-4779
Practice Address - Fax:919-556-5277
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201301175208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics