Healthcare Provider Details

I. General information

NPI: 1144451774
Provider Name (Legal Business Name): JOHN CARLYN BRAND D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 MEDICAL PARK DR
OSAGE BEACH MO
65065-3000
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-3100
  • Fax: 573-348-8279
Mailing address:
  • Phone: 417-829-4620
  • Fax: 573-348-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011012163
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: