Provider Demographics
NPI:1316300163
Name:LA FUENTE, BRANDON RAY (BCO, BADO)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:RAY
Last Name:LA FUENTE
Suffix:
Gender:M
Credentials:BCO, BADO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 BANDIT PT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-2832
Mailing Address - Country:US
Mailing Address - Phone:405-620-2543
Mailing Address - Fax:
Practice Address - Street 1:2104 BANDIT PT
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73025-2832
Practice Address - Country:US
Practice Address - Phone:405-620-2543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist