Provider Demographics
NPI:1275627598
Name:BRANT, GREGORY CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CHARLES
Last Name:BRANT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 N RIDGE RD W
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-9409
Mailing Address - Country:US
Mailing Address - Phone:440-969-1112
Mailing Address - Fax:440-969-9612
Practice Address - Street 1:4716 N RIDGE RD W
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-9409
Practice Address - Country:US
Practice Address - Phone:440-969-1112
Practice Address - Fax:440-969-9612
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.003654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE00693Medicare UPIN
OHBR0547473Medicare ID - Type Unspecified