Provider Demographics
NPI:1508033622
Name:DR. WILLIAM F. BRIGHAM, OPTOMETRIST INC
Entity Type:Organization
Organization Name:DR. WILLIAM F. BRIGHAM, OPTOMETRIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-422-9421
Mailing Address - Street 1:902 W WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-3976
Mailing Address - Country:US
Mailing Address - Phone:260-422-9421
Mailing Address - Fax:260-422-9422
Practice Address - Street 1:902 W WAYNE ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3976
Practice Address - Country:US
Practice Address - Phone:260-422-9421
Practice Address - Fax:260-422-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001470152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100280170AMedicaid
13275OtherSPECTERA
ININ1470OtherEYEMED
IN200941810AMedicaid
ININ1470OtherEYEMED
IN200941810AMedicaid
966780Medicare Oscar/Certification
13275OtherSPECTERA
0674620001Medicare NSC