Provider Demographics
NPI:1396752572
Name:BRANDT, JOHN PHILIP JR (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILIP
Last Name:BRANDT
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:947 BELLEFONTE AVE
Mailing Address - Street 2:PO BOX 9
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-3033
Mailing Address - Country:US
Mailing Address - Phone:570-748-7751
Mailing Address - Fax:570-748-3967
Practice Address - Street 1:947 BELLEFONTE AVE
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-3033
Practice Address - Country:US
Practice Address - Phone:570-748-7751
Practice Address - Fax:570-748-3967
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012718120001Medicaid
PA195905PREMedicare ID - Type Unspecified
T30092Medicare UPIN