Provider Demographics
NPI:1780618108
Name:BRANT, DOUGLAS WAYNE SR (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:BRANT
Suffix:SR
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 1:6801 NW 39TH EXPRESSWAY
Mailing Address - Street 2:DEACONESS FAMILY CARE BETHANY
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-2501
Mailing Address - Country:US
Mailing Address - Phone:405-789-2441
Mailing Address - Fax:405-789-7978
Practice Address - Street 1:6801 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2501
Practice Address - Country:US
Practice Address - Phone:405-789-2441
Practice Address - Fax:405-789-7978
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100110280AMedicaid
OK080175208OtherMEDICARE RR
OK$$$$$$$$$Medicare PIN
OK100110280AMedicaid