Healthcare Provider Details

I. General information

NPI: 1780942599
Provider Name (Legal Business Name): NICKLAUS BRANDEHOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 FRESNO ST
FRESNO CA
93721-1324
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 559-499-6440
  • Fax:
Mailing address:
  • Phone: 559-443-2682
  • Fax: 559-443-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA127500
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberA127500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: