Provider Demographics
NPI:1205814753
Name:BRANCH, C. RENEE (DO)
Entity Type:Individual
Prefix:
First Name:C.
Middle Name:RENEE
Last Name:BRANCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 ROSELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4246
Mailing Address - Country:US
Mailing Address - Phone:903-533-0644
Mailing Address - Fax:903-592-7849
Practice Address - Street 1:1910 ROSELAND BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4246
Practice Address - Country:US
Practice Address - Phone:903-533-0644
Practice Address - Fax:903-592-7849
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151719501Medicaid
TX0078JEOtherBLUE CROSS BLUE SHIELD
TXP02097550OtherMCRR
TX8JK361OtherBCBS
TX8K2868Medicare PIN