Provider Demographics
NPI:1962102947
Name:MALMSTADT, BRANDON PHILLIP
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:PHILLIP
Last Name:MALMSTADT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-0345
Mailing Address - Country:US
Mailing Address - Phone:360-244-1808
Mailing Address - Fax:
Practice Address - Street 1:950 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2504
Practice Address - Country:US
Practice Address - Phone:360-244-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2024-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61565990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty