Basic Information
| Provider Information | |||||||||
| NPI: | 1457561789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UPTON | ||||||||
| FirstName: | BRANDI | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416173 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 577 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112156065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183691444 | ||||||||
| FaxNumber: | 7183693066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2013032805 | MO | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 2013032805 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 301188 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 06129822 | 05 | NY | MEDICAID | 07933 | 05 | LA | MEDICAID | 1457561789 | 05 | MO | MEDICAID |