Provider Demographics
NPI:1104879931
Name:BRANTLEY, DAVID BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRUCE
Last Name:BRANTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:200 N RIVER ST
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-1659
Practice Address - Country:US
Practice Address - Phone:912-882-4870
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028506207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00327269LMedicaid
GA93BBHSNMedicare ID - Type Unspecified
GAC70594Medicare UPIN