Provider Demographics
NPI:1255408936
Name:BRANTLEY, KENNY M (MD)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:M
Last Name:BRANTLEY
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 1:1215 S COULTER ST
Mailing Address - Street 2:STE 405
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1758
Mailing Address - Country:US
Mailing Address - Phone:806-358-8437
Mailing Address - Fax:
Practice Address - Street 1:1215 S COULTER ST
Practice Address - Street 2:STE 405
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1758
Practice Address - Country:US
Practice Address - Phone:806-358-8437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8472207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046844901Medicaid
TX88927KMedicare ID - Type Unspecified
TX046844901Medicaid