Provider Demographics
NPI:1679663207
Name:BENTZ, BRANDON G (MD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:G
Last Name:BENTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SUMMITVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2715
Mailing Address - Country:US
Mailing Address - Phone:509-248-7849
Mailing Address - Fax:509-248-8291
Practice Address - Street 1:711 N TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2296
Practice Address - Country:US
Practice Address - Phone:970-641-1456
Practice Address - Fax:970-641-4461
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG89294207Y00000X
WA60914678207Y00000X
CODR.0070421207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA874ZOtherPTAN FOR RIDEOUT MEDICAL ASSOCIATES, INC.