Provider Demographics
NPI:1588600530
Name:BRANDON, RICHARD LYLE (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LYLE
Last Name:BRANDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:202 LAKESHORE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558
Mailing Address - Country:US
Mailing Address - Phone:912-673-1771
Mailing Address - Fax:912-673-1811
Practice Address - Street 1:202 LAKESHORE DR
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558
Practice Address - Country:US
Practice Address - Phone:912-673-1771
Practice Address - Fax:912-673-1811
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014890207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00379904AMedicaid
GA00379904AMedicaid
GA16BDSKPMedicare ID - Type Unspecified