Provider Demographics
NPI:1669476602
Name:BOURGEOUS, BRANDON ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ELLIOTT
Last Name:BOURGEOUS
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 1:788 8TH AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-2107
Mailing Address - Country:US
Mailing Address - Phone:319-363-2682
Mailing Address - Fax:319-363-1473
Practice Address - Street 1:788 8TH AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401-2107
Practice Address - Country:US
Practice Address - Phone:319-363-2682
Practice Address - Fax:319-363-1473
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34399207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0254680Medicaid
IA217360002Medicare PIN
IA0254680Medicaid
IAI5586Medicare ID - Type Unspecified