Provider Demographics
NPI:1417067752
Name:BRANDON, PHILIP FRED (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:FRED
Last Name:BRANDON
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 1:1600 W SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5136
Mailing Address - Country:US
Mailing Address - Phone:479-756-1234
Mailing Address - Fax:476-756-1087
Practice Address - Street 1:1600 W SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-5136
Practice Address - Country:US
Practice Address - Phone:479-756-1234
Practice Address - Fax:476-756-1087
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2370152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR17274000040OtherQUALCHOICE
AR47744OtherBCBS
AR0336120001OtherPALMETTO
AR0336120001OtherPALMETTO
AR17274000040OtherQUALCHOICE