Provider Demographics
NPI:1871520742
Name:BRANDAU, KIM M (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:BRANDAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2185
Mailing Address - Country:US
Mailing Address - Phone:714-772-6701
Mailing Address - Fax:714-772-5240
Practice Address - Street 1:450 WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2185
Practice Address - Country:US
Practice Address - Phone:714-772-6701
Practice Address - Fax:714-772-5240
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9740645-1205208D00000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0000190Medicaid
CAGR0000190Medicaid
W5922Medicare ID - Type Unspecified