Provider Demographics
NPI:1619926490
Name:BRANT, THOMAS R (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:BRANT
Suffix:
Gender:M
Credentials:DPM
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 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1100 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-2663
Practice Address - Fax:573-882-1760
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000339213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO24958OtherBLUE CHOICE
MO2709006OtherUNITED HEALTHCARE
MO24958OtherBLUE SHIELD
MO106684OtherHEALTLINK
MO300749421Medicaid
T42853Medicare UPIN
MO24958OtherBLUE SHIELD
MO480013243Medicare PIN
MO2709006OtherUNITED HEALTHCARE
MO300749421Medicaid