Provider Demographics
NPI:1518900950
Name:BRANDT, KIM B (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:B
Last Name:BRANDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 BRENNER RD NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1534
Mailing Address - Country:US
Mailing Address - Phone:319-329-8908
Mailing Address - Fax:
Practice Address - Street 1:3900 CAPITOL MALL DR SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8654
Practice Address - Country:US
Practice Address - Phone:360-754-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20279207Q00000X
WAMD00045715207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1012308Medicaid
WA3076BROtherBSWA
WA8444226Medicaid
WA0236140OtherLIWA VCR
WAP00626487OtherRRGA
WA8873465Medicare PIN
WA8444226Medicaid
WA0236140OtherLIWA VCR