Provider Demographics
NPI:1629164728
Name:BRANDEBERRY, KENT (DO)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:BRANDEBERRY
Suffix:
Gender:M
Credentials:DO
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 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6930
Mailing Address - Country:US
Mailing Address - Phone:513-981-5123
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:3224 JARVIS DR
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807
Practice Address - Country:US
Practice Address - Phone:419-996-5757
Practice Address - Fax:419-996-5913
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003466A207Q00000X
OH34.011107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine