Healthcare Provider Details

I. General information

NPI: 1952397242
Provider Name (Legal Business Name): BRANTLY BAYNES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR 88 MDG/SGH2
WRIGHT PATTERSON AFB OH
45433-5546
US

IV. Provider business mailing address

1121 PURSELL AVE
DAYTON OH
45420-1942
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9123
  • Fax:
Mailing address:
  • Phone: 937-257-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101049687
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: