Provider Demographics
NPI:1114914017
Name:HANLON, BRADY P (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:P
Last Name:HANLON
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 1:1607 SAINT JAMES CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-878-0191
Mailing Address - Fax:850-878-8900
Practice Address - Street 1:1607 SAINT JAMES CT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5352
Practice Address - Country:US
Practice Address - Phone:850-878-0191
Practice Address - Fax:850-878-8900
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003296A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN003OtherDAVIS VISION
IN200517920Medicaid
IN200517920OtherCORESOURCE
IN000000368674OtherANTHEM BCBS
IN200517920OtherHARMONY HEALTH
IN0356760001OtherDMERC
IN200517920OtherMANAGED HEALTH SERVICES
IN200517920OtherMOLINA
IN000000368674OtherANTHEM BCBS
IN200517920OtherMANAGED HEALTH SERVICES