Provider Demographics
NPI:1437248267
Name:BRAGA, ANN RENE (OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:ANN
Middle Name:RENE
Last Name:BRAGA
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 SHOSHONE ST N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6154
Mailing Address - Country:US
Mailing Address - Phone:208-733-1067
Mailing Address - Fax:208-733-7597
Practice Address - Street 1:691 SHOSHONE ST N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6154
Practice Address - Country:US
Practice Address - Phone:208-733-1067
Practice Address - Fax:208-733-7597
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOD485152W00000X
AZ601I156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV2894OtherBLUE CROSS
ID000010014411OtherBLUE SHIELD
IDV2894OtherBLUE CROSS