Provider Demographics
NPI:1952365702
Name:BRINKLEY, JOHN L (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:BRINKLEY
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 1:119 LATONEA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-7572
Mailing Address - Country:US
Mailing Address - Phone:803-798-8642
Mailing Address - Fax:803-798-0422
Practice Address - Street 1:360 HARBISON BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-2248
Practice Address - Country:US
Practice Address - Phone:803-732-8663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC656152W00000X, 152WV0400X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC253936Medicaid
SCT241926690Medicare PIN
SCT24192Medicare UPIN
SCT241926691Medicare PIN
SCT241925531Medicare PIN