IVY L BRACKUP (Credential# 550882) is licensed (Physician/surgeon) with Connecticut Department of Consumer Protection. The license effective date is July 25, 1995. The license expiration date date is April 30, 1996. The license status is INACTIVE.
IVY L BRACKUP is licensed with the Department of Consumer Protection of Connecticut. The credential number is #1.033283. The credential type is physician/surgeon. The effective date is July 25, 1995. The expiration date is April 30, 1996. The business address is Po Drawer J, Zuni, NM 87327. The current status is inactive.
| Licensee Name | IVY L BRACKUP |
| Credential ID | 550882 |
| Credential Number | 1.033283 |
| Credential Type | Physician/Surgeon |
| Business Address |
Po Drawer J Zuni NM 87327 |
| Business Type | INDIVIDUAL |
| Status | INACTIVE - LAPSED DUE TO NON-RENEWAL |
| Issue Date | 1993-08-27 |
| Effective Date | 1995-07-25 |
| Expiration Date | 1996-04-30 |
| Refresh Date | 2009-07-08 |
| ID | Credential Code | Credential Type | Issue | Term | Status |
|---|---|---|---|---|---|
| 161968 | CSP.0021684 | CONTROLLED SUBSTANCE REGISTRATION FOR PRACTITIONER | 1993-12-13 - 1995-07-01 | INACTIVE |
| Street Address | PO DRAWER J |
| City | ZUNI |
| State | NM |
| Zip Code | 87327 |
| Licensee Name | Office Address | Credential | Effective / Expiration |
|---|---|---|---|
| Evan M Benjamin | Ihs Hospital, Zuni, NM 87327 | Physician/surgeon | 1994-03-31 ~ 1995-03-31 |
| City | ZUNI |
| Zip Code | 87327 |
| License Type | Physician/Surgeon |
| License Type + County | Physician/Surgeon + ZUNI |
| Licensee Name | Office Address | Credential | Effective / Expiration |
|---|---|---|---|
| Russell H Harris Md | Envision Physician Services, Horsham, PA 19044 | Physician/surgeon | 2019-09-01 ~ 2020-08-31 |
| Gilbert L Drozdow | Envision Physician Services, Plantation, FL 33322 | Physician/surgeon | 2019-10-01 ~ 2020-09-30 |
| Penny Lamhut Md | Genesis Physician Services, Windsor, CT 06098 | Physician/surgeon | 1999-07-15 ~ 2000-07-31 |
| John T Thompson | Physician Pavilion W, Towson, MD 21204 | Physician/surgeon | 2020-07-01 ~ 2021-06-30 |
| Arnold R Kriegstein | College Physician, New York, NY 10032 | Physician/surgeon | 1993-04-23 ~ 1994-03-31 |
| Catherine Nguyen Keegan | Envision Physician Services, Dallas, TX 75240 | Physician/surgeon | 2020-02-01 ~ 2021-01-31 |
| Brent Robert Jacobson | Envision Physician Services, Dallas, TX 75240 | Physician/surgeon | 2020-09-01 ~ 2021-08-31 |
| Nazanin Barzideh Md | North Shore Retina Physician, Pllc, East Hills, NY 11576 | Physician/surgeon | 2010-05-01 ~ 2011-04-30 |
| Barbara M Galko Md | Danbury Office of Physician Services PC, Danbury, CT 06810 | Physician/surgeon | 2010-06-01 ~ 2011-05-31 |
| Barbara A Brandes Md | Danbury Office of Physician Services, Danbury, CT 06810 | Physician/surgeon | 2004-07-08 ~ 2005-07-31 |
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| Data Provider | Connecticut Department of Consumer Protection |
| Jurisdiction | Connecticut |
| Related Datasets | Connecticut Business Registrations, Connecticut Child Care Facilities |
This dataset includes 1.41 million licenses issued wtih Connecticut Department of Consumer Protection (TDLR).