Provider Demographics
NPI:1669821070
Name:DEATHERAGE, BRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:
Last Name:DEATHERAGE
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 1:5103 KYLE CENTER DR STE 108
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-6164
Mailing Address - Country:US
Mailing Address - Phone:877-324-3310
Mailing Address - Fax:
Practice Address - Street 1:5103 KYLE CENTER DR STE 108
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6164
Practice Address - Country:US
Practice Address - Phone:877-324-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT509882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10057590OtherPHYSICIANS-IN-TRAINING PERMIT