Provider Demographics
NPI:1811958051
Name:BRANNON, HEATHER L (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:BRANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E BUTLER RD
Mailing Address - Street 2:STE C1
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2170
Mailing Address - Country:US
Mailing Address - Phone:864-305-1662
Mailing Address - Fax:864-603-2067
Practice Address - Street 1:211 E BUTLER RD STE C1
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662
Practice Address - Country:US
Practice Address - Phone:864-305-1662
Practice Address - Fax:864-603-2067
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC280136Medicaid
H80230Medicare UPIN
SCH802306905Medicare PIN
SC280136Medicaid