Provider Demographics
NPI:1144451774
Name:BRAND, JOHN CARLYN (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CARLYN
Last Name:BRAND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:573-348-8309
Practice Address - Street 1:1057 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3000
Practice Address - Country:US
Practice Address - Phone:573-302-3100
Practice Address - Fax:573-348-8279
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011012163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011012163OtherMO STATE LICENSE
MO1144451774Medicaid
MO132300190Medicare PIN
MO431560263OtherTRICARE
MO1144451774Medicare UPIN
MO132680444Medicare PIN