Healthcare Provider Details

I. General information

NPI: 1629164728
Provider Name (Legal Business Name): KENT BRANDEBERRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3224 JARVIS DR
LIMA OH
45807
US

IV. Provider business mailing address

PO BOX 636930
CINCINNATI OH
45263-6930
US

V. Phone/Fax

Practice location:
  • Phone: 419-996-5757
  • Fax: 419-996-5913
Mailing address:
  • Phone: 513-981-5123
  • Fax: 513-981-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003466A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.011107
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: