Provider Demographics
NPI:1407196801
Name:LONGENECKER, BRANDON SETH (DO)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:SETH
Last Name:LONGENECKER
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 1:380 E 1500 S STE 202
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3942
Mailing Address - Country:US
Mailing Address - Phone:146-565-7460
Mailing Address - Fax:
Practice Address - Street 1:380 E 1500 S STE 202
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3942
Practice Address - Country:US
Practice Address - Phone:435-657-4600
Practice Address - Fax:435-657-4615
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020315207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program