=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134440365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON MAX MARKUS D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2010
-----------------------------------------------------
Last Update Date | 10/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2783 BROWNWOOD BLVD
-----------------------------------------------------
City | THE VILLAGES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-834-7546
-----------------------------------------------------
Fax | 352-383-1951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1793 13TH ST SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-362-8385
-----------------------------------------------------
Fax | 503-362-8385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | DO154852
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------