Provider Demographics
NPI:1952308546
Name:BRANSON, GLENN ALAN (OD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ALAN
Last Name:BRANSON
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 1:1 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4927
Mailing Address - Country:US
Mailing Address - Phone:573-332-8500
Mailing Address - Fax:573-335-5080
Practice Address - Street 1:1 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4927
Practice Address - Country:US
Practice Address - Phone:573-332-8500
Practice Address - Fax:573-335-5080
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT96068Medicare UPIN
MOT96068Medicare UPIN