Provider Demographics
NPI:1871710095
Name:BRACKETT, MARY JANE MORAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY JANE
Middle Name:MORAN
Last Name:BRACKETT
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:PO BOX 492
Mailing Address - Street 2:45 LITCHFIELD ROAD
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-1944
Mailing Address - Country:US
Mailing Address - Phone:860-274-5408
Mailing Address - Fax:860-274-5408
Practice Address - Street 1:45 LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-1944
Practice Address - Country:US
Practice Address - Phone:860-274-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine