Provider Demographics
NPI:1194949883
Name:BRANDON, JONATHAN LIGHTFOOT (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LIGHTFOOT
Last Name:BRANDON
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 1:1746 COLE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1746 COLE BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3208
Practice Address - Country:US
Practice Address - Phone:303-914-8800
Practice Address - Fax:303-716-3777
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY588352085P0229X
CO502152085P0229X
NC2013-016852085R0202X
CODR.00502152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA108747Medicare PIN
COCOA108098Medicare PIN