Provider Demographics
NPI:1346334422
Name:BRABHAM, ANNETTE (OD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:BRABHAM
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 1:111 N JOHN SIMS PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1005
Mailing Address - Country:US
Mailing Address - Phone:850-729-8711
Mailing Address - Fax:850-729-8713
Practice Address - Street 1:111 N JOHN SIMS PKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580
Practice Address - Country:US
Practice Address - Phone:850-729-8711
Practice Address - Fax:850-729-8713
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0002698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620523200Medicaid
FL620523200Medicaid
FLU43493Medicare UPIN
FL3871390001Medicare NSC