Provider Demographics
NPI:1477733780
Name:BRENDA DEFORREST OD PA
Entity type:Organization
Organization Name:BRENDA DEFORREST OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFORREST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-298-8819
Mailing Address - Street 1:4884 S KIRKMAN RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-3641
Mailing Address - Country:US
Mailing Address - Phone:407-289-8819
Mailing Address - Fax:
Practice Address - Street 1:4884 S KIRKMAN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-3641
Practice Address - Country:US
Practice Address - Phone:407-289-8819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL2617261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJA488AMedicare PIN