Provider Demographics
NPI:1841498680
Name:BRACKEN, MARY ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BRACKEN
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 1:3357 S WAKEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-1718
Mailing Address - Country:US
Mailing Address - Phone:240-304-0165
Mailing Address - Fax:
Practice Address - Street 1:2015 MARTINS GRANT CT
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032
Practice Address - Country:US
Practice Address - Phone:410-721-6353
Practice Address - Fax:410-721-2071
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046739207R00000X
MDD0042596207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine