Provider Demographics
NPI:1154325819
Name:FRY, BRENT B (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:B
Last Name:FRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11121 KINGSTON PIKE
Mailing Address - Street 2:STE A
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2890
Mailing Address - Country:US
Mailing Address - Phone:865-966-0100
Mailing Address - Fax:865-966-0007
Practice Address - Street 1:11121 KINGSTON PIKE
Practice Address - Street 2:STE A
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2890
Practice Address - Country:US
Practice Address - Phone:865-966-0100
Practice Address - Fax:865-966-0007
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTNOD1904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU92848Medicare UPIN
TN3945672Medicare ID - Type Unspecified