Provider Demographics
NPI:1568456853
Name:WILSON, BRANDI D (MD)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:D
Last Name:WILSON
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 1:5675 ROE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROELAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2538
Mailing Address - Country:US
Mailing Address - Phone:913-432-2080
Mailing Address - Fax:913-432-5183
Practice Address - Street 1:840 37TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6502
Practice Address - Country:US
Practice Address - Phone:772-567-6412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0430206207V00000X
FLME160442207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100458990AMedicaid
KS103098Medicare ID - Type Unspecified
MOB29C523Medicare ID - Type Unspecified
H88001Medicare UPIN