Provider Demographics
NPI:1508027277
Name:WALLEY, BRANDON W (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:W
Last Name:WALLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:358 NEW BYHALIA RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-3743
Mailing Address - Country:US
Mailing Address - Phone:901-853-8180
Mailing Address - Fax:901-853-1421
Practice Address - Street 1:358 NEW BYHALIA RD
Practice Address - Street 2:SUITE 3
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-3743
Practice Address - Country:US
Practice Address - Phone:901-853-8180
Practice Address - Fax:901-853-1421
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS805152W00000X
TN2811152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS805OtherMS LICENSE
11861175OtherCAQH
TN2811OtherTN LICENSE