Provider Demographics
NPI:1376570424
Name:BRANDON, ALBERT R JR (DO)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:R
Last Name:BRANDON
Suffix:JR
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 1:482 INTERSTATE DR
Mailing Address - Street 2:STE A
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3109
Mailing Address - Country:US
Mailing Address - Phone:931-728-4718
Mailing Address - Fax:931-728-1016
Practice Address - Street 1:482 INTERSTATE DR
Practice Address - Street 2:STE A
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3109
Practice Address - Country:US
Practice Address - Phone:931-728-4718
Practice Address - Fax:931-728-1016
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4107876OtherBC
TN37-30155Medicaid
3730155Medicare ID - Type Unspecified
3332964Medicare ID - Type Unspecified
TN37-30155Medicaid