Provider Demographics
NPI:1982602728
Name:BRANSON, LOWELL PARDEE (0D)
Entity Type:Individual
Prefix:
First Name:LOWELL
Middle Name:PARDEE
Last Name:BRANSON
Suffix:
Gender:M
Credentials:0D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8332 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3441
Mailing Address - Country:US
Mailing Address - Phone:602-944-2656
Mailing Address - Fax:602-870-4605
Practice Address - Street 1:8332 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3441
Practice Address - Country:US
Practice Address - Phone:602-944-2656
Practice Address - Fax:602-870-4605
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0450860001OtherDMERC
AZ035594OtherAHCCCS
AZ0450860001OtherDMERC