Provider Demographics
NPI:1932495470
Name:PAGE, BRANDON (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:PAGE
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:441 WALL BLVD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7723
Practice Address - Country:US
Practice Address - Phone:504-371-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11016017207Q00000X
LAMD.207152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00101241Medicaid
LA2371428Medicaid
LA365877YH3UMedicare PIN