Provider Demographics
NPI:1255635348
Name:ANNETTE BRABHAM OD PA
Entity type:Organization
Organization Name:ANNETTE BRABHAM OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRABHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-729-8711
Mailing Address - Street 1:111 N JOHN SIMS PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1005
Mailing Address - Country:US
Mailing Address - Phone:850-729-8711
Mailing Address - Fax:850-729-8713
Practice Address - Street 1:111 N JOHN SIMS PKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1005
Practice Address - Country:US
Practice Address - Phone:850-729-8711
Practice Address - Fax:850-729-8713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0002698152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620523200Medicaid
FLU43493Medicare UPIN
FL3871390001Medicare NSC
FL620523200Medicaid