Provider Demographics
NPI:1316093529
Name:BRANDT, GWEN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:GWEN
Middle Name:MARIE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:MARIE
Other - Last Name:VELDHOF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 228
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:200 JEFFERSON SE
Practice Address - Street 2:STE 549
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-1835
Practice Address - Fax:616-685-1846
Is Sole Proprietor?:No
Enumeration Date:2007-01-28
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085852207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM02830195Medicare PIN