Provider Demographics
NPI:1790708733
Name:CRANDON, BRENT THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:THOMAS
Last Name:CRANDON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1019 MASSACHUSETTS ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2923
Mailing Address - Country:US
Mailing Address - Phone:785-843-3844
Mailing Address - Fax:785-331-2496
Practice Address - Street 1:1019 MASSACHUSETTS ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2923
Practice Address - Country:US
Practice Address - Phone:785-843-3844
Practice Address - Fax:785-331-2496
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1297152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0409160001Medicare NSC
KSU13955Medicare UPIN
KS049814Medicare PIN