Provider Demographics
NPI:1235651514
Name:DMYTRUK, BRANDON GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:GEORGE
Last Name:DMYTRUK
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 1:5312 OUTLOOK BLVD APT 9302
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1569
Mailing Address - Country:US
Mailing Address - Phone:630-995-6173
Mailing Address - Fax:
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-584-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-08
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0065006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty