Healthcare Provider Details

I. General information

NPI: 1912131079
Provider Name (Legal Business Name): JOHN ROBERT BRANDENBURG D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1562
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax:
Mailing address:
  • Phone: 740-446-5387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number03419
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: