Provider Demographics
NPI: | 1366500183 |
---|---|
Name: | BRILLIANT, RICHARD L (OPTOMETRY) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RICHARD |
Middle Name: | L |
Last Name: | BRILLIANT |
Suffix: | |
Gender: | M |
Credentials: | OPTOMETRY |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 4 HIDDEN ACRES DR |
Mailing Address - Street 2: | |
Mailing Address - City: | TABERNACLE |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 08088-8586 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | 215-276-1329 |
Practice Address - Street 1: | 100 W SPROUL RD |
Practice Address - Street 2: | SUITE 125 |
Practice Address - City: | SPRINGFIELD |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19064-2033 |
Practice Address - Country: | US |
Practice Address - Phone: | 610-690-4900 |
Practice Address - Fax: | 610-690-4910 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-12-05 |
Last Update Date: | 2016-09-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | OEG000447 | 152WL0500X, 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152WL0500X | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation |
No | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 67097 | Other | BLUE SHIELD |
PA | T28112 | Medicare UPIN | |
PA | 67097 | Other | BLUE SHIELD |