Healthcare Provider Details

I. General information

NPI: 1144629973
Provider Name (Legal Business Name): BRANDON UNGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18800 JOHNSTON RD
SIDNEY OH
45365-9755
US

IV. Provider business mailing address

121 S OPERA ST
BELLEFONTAINE OH
43311-2057
US

V. Phone/Fax

Practice location:
  • Phone: 937-492-5930
  • Fax:
Mailing address:
  • Phone: 937-498-1354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberSP 8904
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: