Provider Demographics
NPI:1740413558
Name:SCHWARTZ, BRANDON WAYNE (IDC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WAYNE
Last Name:SCHWARTZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SPECIAL BOAT TEAM 22
Mailing Address - Street 2:2603 LOWER GAINESVILLE ROAD
Mailing Address - City:STENNIS SPACE CENTER
Mailing Address - State:MS
Mailing Address - Zip Code:39529-0001
Mailing Address - Country:US
Mailing Address - Phone:228-365-2306
Mailing Address - Fax:
Practice Address - Street 1:SPECIAL BOAT TEAM 22
Practice Address - Street 2:2603 LOWER GAINESVILLE ROAD
Practice Address - City:STENNIS SPACE CENTER
Practice Address - State:MS
Practice Address - Zip Code:39529-0001
Practice Address - Country:US
Practice Address - Phone:228-365-2306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman