Provider Demographics
NPI:1336168137
Name:BRANDT, JON MARC (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:MARC
Last Name:BRANDT
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 1:644 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3512
Mailing Address - Country:US
Mailing Address - Phone:920-621-1362
Mailing Address - Fax:
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-431-3189
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI406812080P0207X, 2080P0207X
MI43010756352080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G86057Medicare UPIN
07125-0132Medicare ID - Type Unspecified
WI32507900Medicare ID - Type Unspecified