Provider Demographics
NPI:1568448538
Name:BRANSFORD, CHARLES WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
Last Name:BRANSFORD
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 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 GREELEY ST S
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5935
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-439-1928
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25254207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30453400Medicaid
MN304203100Medicaid
MN304203100Medicaid
WI000956150Medicare PIN
MNA95872Medicare UPIN
P00202262Medicare PIN