Provider Demographics
NPI:1295735702
Name:BLAIR, BRANDON A (OD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:A
Last Name:BLAIR
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 1:1511 M ST
Mailing Address - Street 2:BOX 263
Mailing Address - City:ORD
Mailing Address - State:NE
Mailing Address - Zip Code:68862-1428
Mailing Address - Country:US
Mailing Address - Phone:308-728-3229
Mailing Address - Fax:308-728-5908
Practice Address - Street 1:1511 M ST
Practice Address - Street 2:BOX 263
Practice Address - City:ORD
Practice Address - State:NE
Practice Address - Zip Code:68862-1428
Practice Address - Country:US
Practice Address - Phone:308-728-3229
Practice Address - Fax:308-728-5908
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1158152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47063736303Medicaid
NE06753OtherBLUE CROSS BLUE SHIELD
NE47063736302Medicaid
NE098964Medicare ID - Type UnspecifiedGROUP NUMBER
NE1245308253Medicare NSC
NE273195Medicare ID - Type UnspecifiedINDIVIDUAL
NE0382230001Medicare NSC
NE47063736302Medicaid
NE47063736303Medicaid