Provider Demographics
NPI:1285870626
Name:BRANNON, BYRON KEITH
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:KEITH
Last Name:BRANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10613 REITER DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6020
Mailing Address - Country:US
Mailing Address - Phone:405-455-7278
Mailing Address - Fax:
Practice Address - Street 1:10613 REITER DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-6020
Practice Address - Country:US
Practice Address - Phone:405-455-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK110963Medicaid