Provider Demographics
NPI:1154323657
Name:BRANDEL, RICHARD GLENN (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GLENN
Last Name:BRANDEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 FRANCIS PL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2465
Mailing Address - Country:US
Mailing Address - Phone:314-726-2377
Mailing Address - Fax:314-726-2397
Practice Address - Street 1:950 FRANCIS PL
Practice Address - Street 2:SUITE 2
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-2465
Practice Address - Country:US
Practice Address - Phone:314-726-2377
Practice Address - Fax:314-726-2397
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000482213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO301731907Medicaid
MO000021368Medicare ID - Type Unspecified
MO301731907Medicaid