Provider Demographics
NPI:1073511184
Name:BRANDON MEDICAL, LLC
Entity Type:Organization
Organization Name:BRANDON MEDICAL, LLC
Other - Org Name:BRANDON MEDICAL, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-478-2845
Mailing Address - Street 1:PO BOX 684
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-0684
Mailing Address - Country:US
Mailing Address - Phone:918-478-2845
Mailing Address - Fax:918-478-5519
Practice Address - Street 1:110 NORTH LEE STREET
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434
Practice Address - Country:US
Practice Address - Phone:918-478-2845
Practice Address - Fax:918-478-5519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100812890AMedicaid
OK100812890AMedicaid