Provider Demographics
NPI:1750490660
Name:WEST, BRANDON A (DO)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:A
Last Name:WEST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4868
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4868
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:1133 CALL PL STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3076
Practice Address - Country:US
Practice Address - Phone:208-232-1000
Practice Address - Fax:208-232-1006
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806053800Medicaid
IDS5817OtherBLUE CROSS
IDH92349Medicare UPIN