1457343576 NPI number — DR. RITA MARIA MEJIA-BRAECKEVELT DO

Table of content: DR. RITA MARIA MEJIA-BRAECKEVELT DO (NPI 1457343576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457343576 NPI number — DR. RITA MARIA MEJIA-BRAECKEVELT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEJIA-BRAECKEVELT
Provider First Name:
RITA
Provider Middle Name:
MARIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SECK
Provider Other First Name:
RITA
Provider Other Middle Name:
MARIA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1457343576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
482 BULLDOG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESQUITE
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89027-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 N SANDHILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89027-4789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-849-0558
Provider Business Practice Location Address Fax Number:
702-346-2147
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  OS12604 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: DO2522 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1743029 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080B610190 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 010056150 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5772254 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 012361100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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