1669482600 NPI number — SARAH P BRANNON OD PC

Table of content: (NPI 1669482600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669482600 NPI number — SARAH P BRANNON OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SARAH P BRANNON OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHANCELLOR EYE CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669482600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12100 KENNEDY LN
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22407-6760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-785-3937
Provider Business Mailing Address Fax Number:
540-785-5498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12100 KENNEDY LN
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22407-6760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-785-3937
Provider Business Practice Location Address Fax Number:
540-785-5498
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRANNON
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
PVLAT
Authorized Official Title or Position:
PRESIDENT/OPTOMETRIST
Authorized Official Telephone Number:
540-785-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000074 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 170333 . This is a "AVESIS PROVIDER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 410048278 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5161390001 . This is a "DMES/ MEDICARE SUPPLIES" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 902137 . This is a "BLOCK PROVIDER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4091903 . This is a "AETNA PROVIDER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 452927 . This is a "ANTHEM BC/BS PROVIDER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 32467 . This is a "MAMSI /UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 09235591 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2150133 . This is a "FIRST HEALTH/MAILHANDLERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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