Provider Demographics
NPI:1306057641
Name:BREVIG, BRANDON MICAH (DO)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:MICAH
Last Name:BREVIG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2032 E SIDEWINDER DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5867
Mailing Address - Country:US
Mailing Address - Phone:208-488-8408
Mailing Address - Fax:888-913-3862
Practice Address - Street 1:302 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6039
Practice Address - Country:US
Practice Address - Phone:208-994-4962
Practice Address - Fax:888-913-3862
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11-6037195208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-6037195OtherGERALD TEPLITZ, DO