Healthcare Provider Details

I. General information

NPI: 1871520742
Provider Name (Legal Business Name): KIM M BRANDAU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

IV. Provider business mailing address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

V. Phone/Fax

Practice location:
  • Phone: 714-772-6701
  • Fax: 714-772-5240
Mailing address:
  • Phone: 714-772-6701
  • Fax: 714-772-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9740645-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number9740645-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierGR0000190
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: