Basic Information
| Provider Information | |||||||||
| NPI: | 1265443436 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3889 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376023889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232302100 | ||||||||
| FaxNumber: | 4232302112 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PROFESSIONAL PARK PVT DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376632288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232397300 | ||||||||
| FaxNumber: | 4232398581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17195 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3023011 | 05 | TN | MEDICAID | 005617677 | 05 | VA | MEDICAID |