Provider Demographics
NPI:1639522642
Name:CALLOW, BRANDON (OD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CALLOW
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 1:9610 LIMA ROAD SUITE 103
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818
Mailing Address - Country:US
Mailing Address - Phone:260-440-8388
Mailing Address - Fax:260-999-5645
Practice Address - Street 1:9610 LIMA ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9998
Practice Address - Country:US
Practice Address - Phone:260-440-8388
Practice Address - Fax:260-999-5645
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003992A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist