Provider Demographics
NPI:1255331450
Name:BRANDT, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
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 1:9422 SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70807-3951
Mailing Address - Country:US
Mailing Address - Phone:225-774-1822
Mailing Address - Fax:225-774-1836
Practice Address - Street 1:9422 SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-3951
Practice Address - Country:US
Practice Address - Phone:225-774-1822
Practice Address - Fax:225-774-1836
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017647208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4331551460OtherBLUE CROSS
LA930114663OtherRRM
LA1359670Medicaid
LAB64039Medicare UPIN
LA4331551460OtherBLUE CROSS
LA52679DE56Medicare PIN