Provider Demographics
NPI:1346299773
Name:BRANTLEY, JONATHAN NATHANIEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:NATHANIEL
Last Name:BRANTLEY
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:SURGICAL SERVICE (112H)
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23249-0001
Mailing Address - Country:US
Mailing Address - Phone:804-675-5112
Mailing Address - Fax:804-675-5390
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:SURGICAL SERVICE (112H)
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5112
Practice Address - Fax:804-675-5390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0103000902213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA19384Medicare UPIN