Provider Demographics
NPI:1063409548
Name:BLARE, BRYAN (OD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:BLARE
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:PO BOX 31001-3246
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:955 W SOUTHERN AVE STE 122
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4903
Practice Address - Country:US
Practice Address - Phone:480-835-4440
Practice Address - Fax:480-835-8882
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ712152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162076Medicare PIN
AZZ162074Medicare PIN
AZZ163196Medicare PIN
AZT41406Medicare UPIN
AZZ114352Medicare PIN