Provider Demographics
NPI:1205458650
Name:BRANDON, JOSHUA (MD)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3101 POPLAR LEVEL RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1076
Practice Address - Country:US
Practice Address - Phone:502-636-7444
Practice Address - Fax:502-636-7112
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY58196207Q00000X
IL125075684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100911900Medicaid
KY58196OtherSTATE LICENSE