Provider Demographics
NPI:1245301746
Name:ORMISTON, BRENTON DOUGLAS (OD)
Entity type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:DOUGLAS
Last Name:ORMISTON
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 1:2808 E WINSTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4450
Mailing Address - Country:US
Mailing Address - Phone:812-361-5864
Mailing Address - Fax:
Practice Address - Street 1:3275 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-4835
Practice Address - Country:US
Practice Address - Phone:812-287-8742
Practice Address - Fax:812-287-8752
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT-2544152W00000X
IN18003561A152W00000X, 152W00000X
KY1833DT152W00000X
LA1595-628T152W00000X, 152W00000X
OH5992152W00000X, 152W00000X
TX8142T152W00000X, 152W00000X
MI4901004511152W00000X
NE1286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist