Provider Demographics
NPI:1578675773
Name:BURRY, BRIAN T (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:BURRY
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 1:1804 OAKLEY SEAVER DR
Mailing Address - Street 2:STE B
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1925
Mailing Address - Country:US
Mailing Address - Phone:407-933-7800
Mailing Address - Fax:
Practice Address - Street 1:1804 OAKLEY SEAVER DR
Practice Address - Street 2:STE B
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1925
Practice Address - Country:US
Practice Address - Phone:407-933-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC-2729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC030XOtherPTAN
FL621175500Medicaid