Provider Demographics
NPI:1639123920
Name:BRANTLEY, GERALD K (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:K
Last Name:BRANTLEY
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 1:1023 KEITH DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-2948
Mailing Address - Country:US
Mailing Address - Phone:478-988-1100
Mailing Address - Fax:478-988-8211
Practice Address - Street 1:1023 KEITH DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2948
Practice Address - Country:US
Practice Address - Phone:478-988-1100
Practice Address - Fax:478-988-8211
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033535207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00502752BMedicaid
GA00502752BMedicaid
GA11BDPLZMedicare ID - Type Unspecified