Provider Demographics
NPI:1255547295
Name:FORREST, BRETT WAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:WAYNE
Last Name:FORREST
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 1:4200 CONROY RD
Mailing Address - Street 2:SPACE L-201
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-2400
Mailing Address - Country:US
Mailing Address - Phone:407-903-1018
Mailing Address - Fax:407-903-1063
Practice Address - Street 1:4200 CONROY RD
Practice Address - Street 2:SPACE L-201
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-2400
Practice Address - Country:US
Practice Address - Phone:407-903-1018
Practice Address - Fax:407-903-1063
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2587152WC0802X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1356OtherARIZONA LICENSE
FLOPC2587OtherLICENSE NUMBER
FL078940200Medicaid
FLOPC2587OtherLICENSE NUMBER