Provider Demographics
NPI:1629286075
Name:HIDER, BRANDON KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:KEITH
Last Name:HIDER
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 1:12895 HIGHWAY 90
Mailing Address - Street 2:SUITE H
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-2249
Mailing Address - Country:US
Mailing Address - Phone:985-331-9400
Mailing Address - Fax:985-331-9401
Practice Address - Street 1:12895 HIGHWAY 90
Practice Address - Street 2:SUITE H
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-2249
Practice Address - Country:US
Practice Address - Phone:985-331-9400
Practice Address - Fax:985-331-9401
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPGY.2-LSUNO207Q00000X
LAMD.204623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05652823Medicaid
LA1505978Medicaid
LA4N912Medicare PIN
LA4N9127061Medicare PIN