Provider Demographics
NPI:1992738629
Name:BRACEY, PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:BRACEY
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:PO BOX 5789
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6841 FERN AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-868-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.025069207P00000X
MS17686207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05286360Medicaid
MS930002963Medicare ID - Type Unspecified
MS05286360Medicaid