Provider Demographics
NPI:1689907206
Name:BRANSCOMB, NICHOLAS (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BRANSCOMB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:NIC
Other - Middle Name:T
Other - Last Name:BRANSCOMB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:36475 FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1971
Mailing Address - Country:US
Mailing Address - Phone:734-655-1290
Mailing Address - Fax:734-655-1270
Practice Address - Street 1:36475 FIVE MILE ROAD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-1290
Practice Address - Fax:734-655-1270
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO2210207R00000X
MI5101018979207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine