Healthcare Provider Details

I. General information

NPI: 1912407172
Provider Name (Legal Business Name): BRANDON EUGENE FORNWALT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18699 N 67TH AVE STE 300
GLENDALE AZ
85308-7149
US

IV. Provider business mailing address

9097 E DESERT COVE AVE STE 200
SCOTTSDALE AZ
85260-6280
US

V. Phone/Fax

Practice location:
  • Phone: 623-566-4718
  • Fax: 523-566-4820
Mailing address:
  • Phone: 928-614-7516
  • Fax: 480-214-9929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number009926
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: