Provider Demographics
NPI:1760595631
Name:BRANTLEY, TODD (OD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:BRANTLEY
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 1:5044 TENNYSON PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-2953
Mailing Address - Country:US
Mailing Address - Phone:972-378-4104
Mailing Address - Fax:972-378-9094
Practice Address - Street 1:5044 TENNYSON PKWY STE B
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2953
Practice Address - Country:US
Practice Address - Phone:972-378-4104
Practice Address - Fax:972-378-9094
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5711 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6849458OtherCIGNA
TX81296QOtherBLUE CROSS BLUE SHIELD
TX7387530OtherAETNA UPIN#
TXU75501Medicare UPIN
TX8F24107Medicare PIN
TX8F0837Medicare ID - Type Unspecified