Provider Demographics
NPI:1811987050
Name:BRANDON, GILBERT THEODORE (MD)
Entity type:Individual
Prefix:
First Name:GILBERT
Middle Name:THEODORE
Last Name:BRANDON
Suffix:
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:PO BOX 3799
Mailing Address - Street 2:DEPT A
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3799
Mailing Address - Country:US
Mailing Address - Phone:931-245-8700
Mailing Address - Fax:931-245-8747
Practice Address - Street 1:1740 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4561
Practice Address - Country:US
Practice Address - Phone:931-245-8700
Practice Address - Fax:931-245-8747
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14164207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3032426Medicaid
TN040008556OtherRR MEDICARE
A99608Medicare UPIN
TN3032426Medicaid