Provider Demographics
NPI:1427114222
Name:WALSH, BRENDAN ROBERT (LICENSED OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:ROBERT
Last Name:WALSH
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 FRANKLIN AVENUE
Mailing Address - Street 2:EXCEL-LENTES, LLC DBA RIVARD OPTICIANS
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-1851
Mailing Address - Country:US
Mailing Address - Phone:860-296-6826
Mailing Address - Fax:860-296-6827
Practice Address - Street 1:323 FRANKLIN AVENUE
Practice Address - Street 2:EXCEL-LENTES, LLC DBA RIVARD OPTICIANS
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1851
Practice Address - Country:US
Practice Address - Phone:860-296-6826
Practice Address - Fax:860-296-6827
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT1316156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4138490001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER