Provider Demographics
NPI:1821019290
Name:FREY, BRANDI MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDI
Middle Name:MARIE
Last Name:FREY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BRANDI
Other - Middle Name:MARIE
Other - Last Name:WARBURTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:210 NW PLEASANT GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986
Mailing Address - Country:US
Mailing Address - Phone:772-621-8777
Mailing Address - Fax:
Practice Address - Street 1:986 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1766
Practice Address - Country:US
Practice Address - Phone:772-621-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000574800Medicaid
FLAM684WMedicare PIN