Provider Demographics
NPI:1790931632
Name:TODD BRANTLEY, OD PA
Entity Type:Organization
Organization Name:TODD BRANTLEY, OD PA
Other - Org Name:LONE STAR VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-378-4104
Mailing Address - Street 1:5425 W SPRING CREEK PKWY
Mailing Address - Street 2:SUITE 145
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-4236
Mailing Address - Country:US
Mailing Address - Phone:972-378-4104
Mailing Address - Fax:972-378-9094
Practice Address - Street 1:5425 W SPRING CREEK PKWY
Practice Address - Street 2:SUITE 145
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-4236
Practice Address - Country:US
Practice Address - Phone:972-378-4104
Practice Address - Fax:972-378-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5711TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A6023Medicare PIN
TXU75501Medicare UPIN