Healthcare Provider Details

I. General information

NPI: 1922687409
Provider Name (Legal Business Name): DANIEL J BRANNEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2021
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE
GREEN BAY WI
54301-3581
US

IV. Provider business mailing address

714 N MICHIGAN ST
SOUTH BEND IN
46601-1035
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4888
  • Fax: 920-430-4889
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number81963-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: