Healthcare Provider Details

I. General information

NPI: 1902500739
Provider Name (Legal Business Name): BRANDON WAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21805 S ELLSWORTH RD STE 111
QUEEN CREEK AZ
85142-9366
US

IV. Provider business mailing address

21805 S ELLSWORTH RD STE 111
QUEEN CREEK AZ
85142-9366
US

V. Phone/Fax

Practice location:
  • Phone: 623-300-9073
  • Fax:
Mailing address:
  • Phone: 623-300-9073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number012271
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: