Provider Demographics
NPI:1366790057
Name:BRANTLEY, BERT ALTON JR (MD)
Entity type:Individual
Prefix:DR
First Name:BERT
Middle Name:ALTON
Last Name:BRANTLEY
Suffix:JR
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 1:2402 FOX CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DAVIDSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21035-1151
Mailing Address - Country:US
Mailing Address - Phone:202-368-9285
Mailing Address - Fax:
Practice Address - Street 1:2402 FOX CREEK LN
Practice Address - Street 2:
Practice Address - City:DAVIDSONVILLE
Practice Address - State:MD
Practice Address - Zip Code:21035-1151
Practice Address - Country:US
Practice Address - Phone:202-368-9285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-043526-L207R00000X
NC24577207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C82946Medicare UPIN