Provider Demographics
NPI:1851302723
Name:MEDINA, BRANDIE JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDIE
Middle Name:JEAN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1208 FLOYD AVE
Mailing Address - Street 2:BLDG C
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2470
Mailing Address - Country:US
Mailing Address - Phone:209-521-7771
Mailing Address - Fax:209-521-4784
Practice Address - Street 1:1208 FLOYD AVE BLDG C
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-2470
Practice Address - Country:US
Practice Address - Phone:209-521-7771
Practice Address - Fax:209-521-4784
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13047152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist