Provider Demographics
NPI:1023153103
Name:BRANSTETTER, HEATHER LEA (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEA
Last Name:BRANSTETTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LEA
Other - Last Name:WOLLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6317 HARRIS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4258
Mailing Address - Country:US
Mailing Address - Phone:817-361-6900
Mailing Address - Fax:817-522-1968
Practice Address - Street 1:6317 HARRIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4258
Practice Address - Country:US
Practice Address - Phone:817-361-6900
Practice Address - Fax:817-522-1968
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6149207R00000X
AKMD4336208000000X
TXR5247207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1014965Medicaid
AK1014965Medicaid
AKK161259Medicare PIN