Provider Demographics
NPI:1295447902
Name:CHILES, BRANDON DEMOND
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:DEMOND
Last Name:CHILES
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 1:6001 GLENCOVE PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-4756
Mailing Address - Country:US
Mailing Address - Phone:405-837-2984
Mailing Address - Fax:
Practice Address - Street 1:6001 GLENCOVE PL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-4756
Practice Address - Country:US
Practice Address - Phone:405-837-2984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty