Provider Demographics
NPI:1083933261
Name:BRANTA, JEFFREY W (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:BRANTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2003
Mailing Address - Country:US
Mailing Address - Phone:708-730-2200
Mailing Address - Fax:708-210-0648
Practice Address - Street 1:100 W 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2003
Practice Address - Country:US
Practice Address - Phone:708-730-2200
Practice Address - Fax:708-210-0648
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine