Provider Demographics
NPI:1184631475
Name:BRAND, JOHN MARION (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARION
Last Name:BRAND
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 1:3893 W 8350 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5005
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:
Practice Address - Street 1:GEORGE E WAHLEN V A MEDICAL CTR
Practice Address - Street 2:500 FOOTHILL BLVD
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-2517
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109296-9934152W00000X
IN18001659A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist