Provider Demographics
NPI:1366494049
Name:BRANSTETTER, LAURA A (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:A
Last Name:BRANSTETTER
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 1:1105 N BUCKNER ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2719
Mailing Address - Country:US
Mailing Address - Phone:316-788-9290
Mailing Address - Fax:316-788-6157
Practice Address - Street 1:1105 N BUCKNER ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2719
Practice Address - Country:US
Practice Address - Phone:316-788-9290
Practice Address - Fax:316-788-6157
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1321-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100279060AMedicaid
KSU34131Medicare UPIN
KS100279060AMedicaid