Provider Demographics
NPI:1619918646
Name:BRANTLY, MARK LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOUIS
Last Name:BRANTLY
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 13833
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-3833
Mailing Address - Country:US
Mailing Address - Phone:352-273-8737
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-8737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83377207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255830100Medicaid
E1827ZMedicare PIN
FL255830100Medicaid
FLE1827ZMedicare PIN