Provider Demographics
NPI:1720083033
Name:BRANTLEY, JAMES J (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:BRANTLEY
Suffix:
Gender:M
Credentials:DPM
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 8728
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0013
Mailing Address - Country:US
Mailing Address - Phone:479-582-1199
Mailing Address - Fax:479-582-1194
Practice Address - Street 1:2828 E MILLENNIUM PL
Practice Address - Street 2:SUITE 2
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6514
Practice Address - Country:US
Practice Address - Phone:479-582-1199
Practice Address - Fax:479-582-1194
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR152213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11443421OtherCAQH PROVIDER NUMBER
AR152OtherSTATE PODIATRY LICENSE
ARU61647Medicare UPIN
AR11443421OtherCAQH PROVIDER NUMBER