Basic Information
Provider Information | |||||||||
NPI: | 1356685572 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANT | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | KYLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 EVES DR # A | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080533195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092679400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 994 W SHERMAN AVE | ||||||||
Address2: |   | ||||||||
City: | VINELAND | ||||||||
State: | NJ | ||||||||
PostalCode: | 083606937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566960900 | ||||||||
FaxNumber: | 8566924769 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2012 | ||||||||
LastUpdateDate: | 05/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   | NJ | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 213ES0103X | 25MD00324400 | NJ | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.