Provider Demographics
NPI:1063834125
Name:DR BRANDON J WILT DPM LLC
Entity type:Organization
Organization Name:DR BRANDON J WILT DPM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-623-6191
Mailing Address - Street 1:138 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7028
Mailing Address - Country:US
Mailing Address - Phone:814-623-6191
Mailing Address - Fax:814-623-5519
Practice Address - Street 1:138 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7028
Practice Address - Country:US
Practice Address - Phone:814-623-6191
Practice Address - Fax:814-623-5519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006021213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty