Provider Demographics
NPI:1912407172
Name:FORNWALT, BRANDON EUGENE
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:EUGENE
Last Name:FORNWALT
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 1:9097 E DESERT COVE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6280
Mailing Address - Country:US
Mailing Address - Phone:928-614-7516
Mailing Address - Fax:480-214-9929
Practice Address - Street 1:18699 N 67TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7149
Practice Address - Country:US
Practice Address - Phone:623-566-4718
Practice Address - Fax:523-566-4820
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009926207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology