Provider Demographics
NPI:1417900036
Name:BRIAN K SHANDLEY
Entity Type:Organization
Organization Name:BRIAN K SHANDLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-299-8188
Mailing Address - Street 1:120 HWY 332 W
Mailing Address - Street 2:STE A5
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-4017
Mailing Address - Country:US
Mailing Address - Phone:979-297-8188
Mailing Address - Fax:979-297-5410
Practice Address - Street 1:120 HWY 332 W
Practice Address - Street 2:STE A5
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4017
Practice Address - Country:US
Practice Address - Phone:979-297-8188
Practice Address - Fax:979-297-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5022TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00345VMedicare ID - Type Unspecified
U50366Medicare UPIN