Provider Demographics
NPI:1326442559
Name:DAVID, BROOKE MILLISON LANE (OD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MILLISON LANE
Last Name:DAVID
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-7528
Mailing Address - Country:US
Mailing Address - Phone:931-456-2728
Mailing Address - Fax:931-456-5446
Practice Address - Street 1:6101 LEE HWY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2932
Practice Address - Country:US
Practice Address - Phone:423-954-1746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1847152W00000X
TNOD3477152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist