Provider Demographics
NPI:1912104969
Name:SHANDLEY, BRIAN K (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:SHANDLEY
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 1:120 HIGHWAY 332 W
Mailing Address - Street 2:STE A5
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-4020
Mailing Address - Country:US
Mailing Address - Phone:979-297-8188
Mailing Address - Fax:979-297-5410
Practice Address - Street 1:120 HIGHWAY 332 W
Practice Address - Street 2:STE A5
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4020
Practice Address - Country:US
Practice Address - Phone:979-297-8188
Practice Address - Fax:979-297-5410
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5022TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161005701Medicaid
TXU50366Medicare UPIN
TX00345VMedicare ID - Type Unspecified