Healthcare Provider Details

I. General information

NPI: 1174594766
Provider Name (Legal Business Name): TODD D BRANDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 10/17/2022
Certification Date: 10/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 E MAUMEE ST STE 102
ANGOLA IN
46703-2044
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-668-8633
  • Fax: 260-668-7563
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01053917A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: