Provider Demographics
NPI:1649385519
Name:BRANDENBERGER, E JON
Entity Type:Individual
Prefix:DR
First Name:E
Middle Name:JON
Last Name:BRANDENBERGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST STE 120
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4764
Practice Address - Country:US
Practice Address - Phone:260-425-6200
Practice Address - Fax:260-425-6205
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028550A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000595565OtherANTHEM
INP00698403OtherRAILROAD MEDICARE
IN100369280AMedicaid
IND95300Medicare UPIN
IN100369280AMedicaid
IN055250EMedicare ID - Type Unspecified