Provider Demographics
NPI:1508809559
Name:BROWN, AMANDA LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LEIGH
Last Name:BROWN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 CROSSHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-5812
Mailing Address - Country:US
Mailing Address - Phone:904-573-9482
Mailing Address - Fax:904-573-9945
Practice Address - Street 1:9525 CROSSHILL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-5812
Practice Address - Country:US
Practice Address - Phone:904-573-9482
Practice Address - Fax:904-573-9945
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4100152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621078300Medicaid
FLU6422WMedicare UPIN
FL621078300Medicaid
FLV07336Medicare UPIN
FLU6422XMedicare UPIN
FLU6422YMedicare UPIN