Provider Demographics
NPI:1811074669
Name:VASTIS, BROOK A (OD)
Entity type:Individual
Prefix:MS
First Name:BROOK
Middle Name:A
Last Name:VASTIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:BROOK
Other - Middle Name:
Other - Last Name:ARROTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:31519 WINTERPLACE PKWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1894
Mailing Address - Country:US
Mailing Address - Phone:410-749-1545
Mailing Address - Fax:410-742-3707
Practice Address - Street 1:130 FORUM DRIVE SUITE 12
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229
Practice Address - Country:US
Practice Address - Phone:803-788-8204
Practice Address - Fax:803-788-8206
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14312Medicaid