Provider Demographics
NPI:1417440645
Name:TISH, BRANDON JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:JAY
Last Name:TISH
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 1:155 N 35TH AVE W
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-8637
Mailing Address - Country:US
Mailing Address - Phone:641-792-7900
Mailing Address - Fax:
Practice Address - Street 1:100 N 4TH AVE W
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-3103
Practice Address - Country:US
Practice Address - Phone:641-792-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091958152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty