Provider Demographics
NPI:1184821092
Name:BRANDT, DOUGLAS W (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:BRANDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-757-0620
Mailing Address - Fax:
Practice Address - Street 1:3269 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-757-0620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN499332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN073195000Medicaid
MN300006006Medicare PIN
MN300004262Medicare PIN