Provider Demographics
NPI:1104919257
Name:BRANDON, MICHAEL S (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:BRANDON
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 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8054
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:12222 MERIT DR STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-3294
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101661207L00000X
TXK6539207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL93938OtherMEDICARE
ILL94853OtherMEDICARE
MO208862938OtherMEDICAID
IL036084784Medicaid
MO013012982Medicare ID - Type Unspecified
IL036084784Medicaid