Provider Demographics
NPI:1497707152
Name:MYLOTT, BRANDT M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDT
Middle Name:M
Last Name:MYLOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1881
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1881
Mailing Address - Country:US
Mailing Address - Phone:414-288-7184
Mailing Address - Fax:414-288-1664
Practice Address - Street 1:545 N 15TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2237
Practice Address - Country:US
Practice Address - Phone:414-288-7184
Practice Address - Fax:414-288-1664
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42756208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1497707152Medicaid
WI73601 2436Medicare PIN
H58748Medicare UPIN
WI68086 1240Medicare PIN