Provider Demographics
NPI:1568493997
Name:BRANDABUR, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:BRANDABUR
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:105 W 8TH AVE STE 7050
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2362
Practice Address - Country:US
Practice Address - Phone:509-252-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023333207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1031699Medicaid
WA0030011OtherLABOR & INDUSTRY
WABR7060OtherBLUE SHIELD
WAMD336WAOtherALASKA MEDICAID
WA806364300OtherIDAHO MEDICAID
WA8890442OtherMEDICARE PTAN - SNO CO
100005788OtherRAILROAD MEDICARE
WAUS0818959OtherAETNA/USHC PCP
WAUS4217189OtherAETNA/USHC PCP
E52098Medicare UPIN
WAUS0818959OtherAETNA/USHC PCP
000151821Medicare PIN