Provider Demographics
NPI:1174594766
Name:BRANDON, TODD D (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:D
Last Name:BRANDON
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 E MAUMEE ST STE 102
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2044
Practice Address - Country:US
Practice Address - Phone:260-668-8633
Practice Address - Fax:260-668-7563
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053917A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2702061Medicaid
MI104953692Medicaid
IN200326130AMedicaid
IN200326130AMedicaid
MI104953692Medicaid
IN667640UMedicare PIN
INP00375375Medicare PIN