Provider Demographics
NPI:1881687606
Name:BRILLIANT, JO ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:JO
Middle Name:ANNE
Last Name:BRILLIANT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 FOREST DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-1472
Mailing Address - Country:US
Mailing Address - Phone:410-295-3010
Mailing Address - Fax:410-295-3015
Practice Address - Street 1:1410 FOREST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-1472
Practice Address - Country:US
Practice Address - Phone:410-295-3010
Practice Address - Fax:410-295-3015
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD558178800Medicaid
MD558178800Medicaid
MDT59926Medicare UPIN