Provider Demographics
NPI:1063605814
Name:BRANDON, EDEN D (MD)
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:D
Last Name:BRANDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10718 S EWING AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617
Mailing Address - Country:US
Mailing Address - Phone:773-731-5456
Mailing Address - Fax:773-731-5456
Practice Address - Street 1:10718 S EWING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:773-731-5456
Practice Address - Fax:773-731-5456
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00445820OtherMEDICARE RAILROAD
ILG93567Medicare UPIN
ILK44814Medicare PIN