Provider Demographics
NPI:1992700413
Name:BRANDECKER, EDWARD JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:BRANDECKER
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 1:1888 ANTILLEY RD
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5205
Mailing Address - Country:US
Mailing Address - Phone:325-795-9550
Mailing Address - Fax:325-795-9537
Practice Address - Street 1:1888 ANTILLEY RD
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5205
Practice Address - Country:US
Practice Address - Phone:325-795-9550
Practice Address - Fax:325-795-9537
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2508208100000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4223641OtherAETNA
TX8X7151OtherBCBS/ADC
TX102408501Medicaid
TX109067104OtherFIRSTCARE/ADC
81T422OtherBCBS
TX102408503OtherMEDICAID/ADC
109067100OtherFIRSTCARE
TXCR1046OtherMCR RXR
250003414OtherMEDICARE RR
4223641OtherAETNA
TX8X7151OtherBCBS/ADC