Provider Demographics
NPI:1033559026
Name:NIELSEN, BRANDON CLARK (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:CLARK
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3314
Mailing Address - Country:US
Mailing Address - Phone:208-293-8580
Mailing Address - Fax:208-712-1058
Practice Address - Street 1:568 FALLS AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3314
Practice Address - Country:US
Practice Address - Phone:208-284-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14652152W00000X, 152WP0200X, 152WV0400X
IDODP:100311152WP0200X, 152WS0006X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy