Provider Demographics
NPI:1265532428
Name:BRANDT, TIMOTHY DAVID (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:BRANDT
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 1:7906 S PARKSIDE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459
Mailing Address - Country:US
Mailing Address - Phone:708-636-1173
Mailing Address - Fax:708-636-1017
Practice Address - Street 1:7906 S PARKSIDE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459
Practice Address - Country:US
Practice Address - Phone:708-636-1173
Practice Address - Fax:708-636-1017
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3535252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053252Medicaid
793111512OtherRR MEDICARE
IL036053252Medicaid
D13066Medicare UPIN