Provider Demographics
NPI:1609852672
Name:BRANTLEY, KEITH W (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:BRANTLEY
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 1:751 FOREST AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2868
Mailing Address - Country:US
Mailing Address - Phone:740-454-0804
Mailing Address - Fax:740-450-3447
Practice Address - Street 1:751 FOREST AVE
Practice Address - Street 2:STE 301
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2868
Practice Address - Country:US
Practice Address - Phone:740-454-0804
Practice Address - Fax:740-450-3447
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063514B207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0883101Medicaid
OHBR 0718063Medicare ID - Type Unspecified
OH0883101Medicaid