Basic Information
| Provider Information | |||||||||
| NPI: | 1053305052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANTLEY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7200 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529370200 | ||||||||
| FaxNumber: | 2524510056 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278049590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524513100 | ||||||||
| FaxNumber: | 2529373106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 32645 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6262907 | 01 | NC | AENTA | OTHER | 8462532 | 01 | NC | CIGNA HEALTHCARE | OTHER | 891068G | 05 | NC | MEDICAID | 73705 | 01 | NC | MEDCOST | OTHER | 370008638 | 01 | NC | RAILROAD MEDICARE | OTHER | 1068G | 01 | NC | BCBSNC | OTHER | 1735023 | 01 | NC | UNITED HEALTH CARE | OTHER |