Provider Demographics
NPI:1902868011
Name:BRANTLEY, DAMON W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMON
Middle Name:W
Last Name:BRANTLEY
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 1:2040 DAN PROCTOR DRIVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ST. MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3801
Mailing Address - Country:US
Mailing Address - Phone:912-576-6340
Mailing Address - Fax:912-576-6341
Practice Address - Street 1:2040 DAN PROCTOR DRIVE
Practice Address - Street 2:SUITE 240
Practice Address - City:ST. MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3801
Practice Address - Country:US
Practice Address - Phone:912-576-6340
Practice Address - Fax:912-576-6341
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064337208600000X, 208600000X
TN42632208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003101326BMedicaid
TN3000853Medicaid
TN4157581OtherBCBS
TN3000853Medicare PIN
TNP00620989Medicare PIN
051555658Medicare ID - Type Unspecified
TN3000853Medicaid