Provider Demographics
NPI:1396844106
Name:BRANDENBURG, EDWARD PAUL (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:PAUL
Last Name:BRANDENBURG
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 1:1200 W 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79102
Mailing Address - Country:US
Mailing Address - Phone:806-379-8384
Mailing Address - Fax:806-379-8430
Practice Address - Street 1:1200 W 15TH AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79102
Practice Address - Country:US
Practice Address - Phone:806-379-8384
Practice Address - Fax:806-379-8430
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX3452TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E70FOtherBCBS
T12342Medicare UPIN
E70FOtherBCBS