Provider Demographics
NPI:1720123490
Name:BRANTLEY, KEVIN BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRUCE
Last Name:BRANTLEY
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 1:1699 N. WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720
Mailing Address - Country:US
Mailing Address - Phone:386-734-2240
Mailing Address - Fax:386-734-8859
Practice Address - Street 1:1699 N WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-1803
Practice Address - Country:US
Practice Address - Phone:386-734-2240
Practice Address - Fax:386-734-8859
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2989Medicare ID - Type UnspecifiedGROUP NUMBER
FL20984ZMedicare ID - Type UnspecifiedPROVIDER NUMBER