Provider Demographics
NPI:1275500696
Name:BRANTON, JON (OD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:BRANTON
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 1:451 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7229
Mailing Address - Country:US
Mailing Address - Phone:318-222-5555
Mailing Address - Fax:318-222-6414
Practice Address - Street 1:451 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7229
Practice Address - Country:US
Practice Address - Phone:318-222-5555
Practice Address - Fax:318-222-6414
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA841-290T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1314251Medicaid
LA841-290TOtherSTATE LIC#
LA1314251Medicaid
LAT19557Medicare UPIN