Provider Demographics
NPI:1710366018
Name:WACHAL, BRANDON M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:M
Last Name:WACHAL
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 1:600 RIDGELY AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1082
Mailing Address - Country:US
Mailing Address - Phone:410-573-9191
Mailing Address - Fax:410-573-5910
Practice Address - Street 1:600 RIDGELY AVE STE 110
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1082
Practice Address - Country:US
Practice Address - Phone:410-573-9191
Practice Address - Fax:410-573-5910
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0091646207Y00000X, 207YX0007X, 207YS0123X
NE7401207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4695852OtherAETNA
MDD0091646OtherMARYLAND LICENSE
MDFN66-0003OtherCAREFIRST BCBS
MD219423600Medicaid
NE7401OtherTEP NUMBER
MD219423600Medicaid
MD4695852OtherAETNA