Provider Demographics
NPI:1518904127
Name:SMALLWOOD, BRANDON L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:L
Last Name:SMALLWOOD
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 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-202-3363
Mailing Address - Fax:
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-202-3363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01325207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7388297OtherMAMSI
NC5902927Medicaid
NCNCG962AMedicare PIN
7388297OtherMAMSI