Basic Information
| Provider Information | |||||||||
| NPI: | 1588632772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANNON | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST | ||||||||
| Address2: | ORI236 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052711515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 NE 13TH ST | ||||||||
| Address2: | 4G4250 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715125 | ||||||||
| FaxNumber: | 4052713462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 01/26/2011 | ||||||||
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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 | 2085N0904X | 22405 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00315038 | 01 | RAILROAD MEDICARE | OTHER |