Provider Demographics
NPI:1205925237
Name:MEDNICK, BRANDON (MD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MEDNICK
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 1:18167 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 650
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-3528
Mailing Address - Country:US
Mailing Address - Phone:800-507-8874
Mailing Address - Fax:727-507-3618
Practice Address - Street 1:18167 US HWY 19 NORTH
Practice Address - Street 2:SUITE 650
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-9843
Practice Address - Country:US
Practice Address - Phone:727-507-3643
Practice Address - Fax:727-507-3618
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056138207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA344804973AMedicaid
GA93BFBGGMedicare ID - Type Unspecified
GA344804973AMedicaid