Healthcare Provider Details

I. General information

NPI: 1689195505
Provider Name (Legal Business Name): STEVEN T. BRANTINGHAM DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

500 5TH ST
BROOKINGS OR
97415-9702
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2000
  • Fax: 541-412-2018
Mailing address:
  • Phone: 541-412-2000
  • Fax: 541-412-2081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number135000952
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP198976
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: