Provider Demographics
NPI:1720083538
Name:MACY, BRANDON A (DPM)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:A
Last Name:MACY
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 1:1114 RARITAN RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1330
Mailing Address - Country:US
Mailing Address - Phone:732-382-3470
Mailing Address - Fax:732-301-8262
Practice Address - Street 1:1114 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1330
Practice Address - Country:US
Practice Address - Phone:732-382-3470
Practice Address - Fax:732-301-8262
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00126200213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3057101Medicaid
NJ3057101Medicaid