Provider Demographics
NPI:1316370414
Name:SUDDUTH, BRANDON (OD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:SUDDUTH
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 1:11406 SAN JOSE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7953
Mailing Address - Country:US
Mailing Address - Phone:904-260-3839
Mailing Address - Fax:904-260-3604
Practice Address - Street 1:11406 SAN JOSE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7953
Practice Address - Country:US
Practice Address - Phone:904-260-3839
Practice Address - Fax:904-260-3604
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4882152W00000X
FLAPPLYING152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty