Basic Information
| Provider Information | |||||||||
| NPI: | 1235651514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DMYTRUK | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5312 OUTLOOK BLVD APT 9302 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309956173 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195844921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2017 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DR.0065006 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.