Provider Demographics
NPI:1902184534
Name:TIBBITTS, BRANDON JAMES (OD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:TIBBITTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2239
Mailing Address - Country:US
Mailing Address - Phone:719-589-0825
Mailing Address - Fax:719-589-1061
Practice Address - Street 1:2509 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2239
Practice Address - Country:US
Practice Address - Phone:719-589-0825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT3002152W00000X
COOPT2922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA108205Medicare PIN