Provider Demographics
NPI:1215148507
Name:BRANTLEY, ELISE I (MD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:I
Last Name:BRANTLEY
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 1:3030 NW 149TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1849
Mailing Address - Country:US
Mailing Address - Phone:405-562-6222
Mailing Address - Fax:405-562-6522
Practice Address - Street 1:3030 NW 149TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1849
Practice Address - Country:US
Practice Address - Phone:405-562-6222
Practice Address - Fax:405-562-6522
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28488207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4264021Medicare PIN