Provider Demographics
NPI:1154325819
Name:FRY, BRENT B (OD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:B
Last Name:FRY
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11111 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2807
Mailing Address - Country:US
Mailing Address - Phone:865-966-0100
Mailing Address - Fax:865-966-0007
Practice Address - Street 1:11111 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2807
Practice Address - Country:US
Practice Address - Phone:865-966-0100
Practice Address - Fax:865-966-0007
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1904152WC0802X, 152WP0200X, 152WX0102X
TNTNOD1904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU92848Medicare UPIN
TN3945672Medicare ID - Type Unspecified