Provider Demographics
NPI:1669474557
Name:BRIGNOLA, GUY RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:RICHARD
Last Name:BRIGNOLA
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 1:1930 S BROAD ST UNIT 9
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-2328
Mailing Address - Country:US
Mailing Address - Phone:800-448-6767
Mailing Address - Fax:215-339-8103
Practice Address - Street 1:1930 S BROAD ST UNIT 9
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:800-448-6767
Practice Address - Fax:215-339-8103
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000554152W00000X
NJ270A00569800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018341500005Medicaid
PA043773FLBMedicare PIN
PA0018341500005Medicaid