Provider Demographics
NPI:1942301858
Name:MANN, BRIAN G (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:G
Last Name:MANN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:909 HARTFORD TPKE
Mailing Address - Street 2:UNIT D2
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4267
Mailing Address - Country:US
Mailing Address - Phone:860-442-0380
Mailing Address - Fax:860-442-0831
Practice Address - Street 1:909 HARTFORD TPKE
Practice Address - Street 2:UNIT D2
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4267
Practice Address - Country:US
Practice Address - Phone:860-442-0380
Practice Address - Fax:860-442-0831
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT564723OtherCONNECTICARE
CTP462855OtherOXFORD
CT0V2114OtherHEALTH NET
CT090002229CT02OtherANTHEM
CT8744282OtherAETNA
CTT87659Medicare UPIN
CT410000483Medicare PIN
CT4634450001Medicare NSC