Provider Demographics
NPI:1811743586
Name:CROSTHWAIT, BRANDON (BSRT RDMS RVT RDCS)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:CROSTHWAIT
Suffix:
Gender:M
Credentials:BSRT RDMS RVT RDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 KETHLEY RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-9638
Mailing Address - Country:US
Mailing Address - Phone:405-273-5801
Mailing Address - Fax:
Practice Address - Street 1:3315 KETHLEY RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-9638
Practice Address - Country:US
Practice Address - Phone:405-273-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103654156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty