Healthcare Provider Details

I. General information

NPI: 1942434394
Provider Name (Legal Business Name): KRISTEN BRANDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 S RIFE MEDICAL LN
ROGERS AR
72758-1452
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-0200
  • Fax: 479-986-3448
Mailing address:
  • Phone: 314-364-4200
  • Fax: 314-364-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-8071
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-8071
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: