Provider Demographics
NPI:1619157427
Name:BRANTLY, ELISA K (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:K
Last Name:BRANTLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:TX
Mailing Address - Zip Code:79782-0640
Mailing Address - Country:US
Mailing Address - Phone:432-607-3225
Mailing Address - Fax:432-607-3266
Practice Address - Street 1:600 EAST INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:TX
Practice Address - Zip Code:79782-0640
Practice Address - Country:US
Practice Address - Phone:432-607-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9435208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CU434OtherBCBS