Provider Demographics
NPI:1669892261
Name:RETIF, BRANDON JAMES
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:RETIF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 ROSA AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-3419
Mailing Address - Country:US
Mailing Address - Phone:504-481-9540
Mailing Address - Fax:
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:504-481-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.302935207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2361112Medicaid