Healthcare Provider Details

I. General information

NPI: 1073511184
Provider Name (Legal Business Name): BRANDON MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 NORTH LEE STREET
FORT GIBSON OK
74434
US

IV. Provider business mailing address

PO BOX 684
FORT GIBSON OK
74434-0684
US

V. Phone/Fax

Practice location:
  • Phone: 918-478-2845
  • Fax: 918-478-5519
Mailing address:
  • Phone: 918-478-2845
  • Fax: 918-478-5519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: STEVEN M BRANDON
Title or Position: PRESIDENT
Credential:
Phone: 918-478-2845