Healthcare Provider Details

I. General information

NPI: 1902868011
Provider Name (Legal Business Name): DAMON W. BRANTLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 DAN PROCTOR DRIVE SUITE 240
ST. MARYS GA
31558-3801
US

IV. Provider business mailing address

2040 DAN PROCTOR DRIVE SUITE 240
ST. MARYS GA
31558-3801
US

V. Phone/Fax

Practice location:
  • Phone: 912-576-6340
  • Fax: 912-576-6341
Mailing address:
  • Phone: 912-576-6340
  • Fax: 912-576-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number064337
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: