Provider Demographics
NPI:1831197060
Name:BRANDT, TERESA PULLARA (MD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:PULLARA
Last Name:BRANDT
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 1:621 MEDICAL CARE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5942
Mailing Address - Country:US
Mailing Address - Phone:813-657-3330
Mailing Address - Fax:813-657-3348
Practice Address - Street 1:621 MEDICAL CARE DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5942
Practice Address - Country:US
Practice Address - Phone:813-657-3330
Practice Address - Fax:813-657-3348
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038477174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30404OtherBC/BS
FL068641700Medicaid
FL30404OtherBC/BS
FLD53976Medicare UPIN
FLK3965Medicare ID - Type UnspecifiedGROUP ID