Provider Demographics
NPI:1053489294
Name:BRANDES, LYNN (OD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:BRANDES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KENNEDY ROAD
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 TORREY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4849
Practice Address - Country:US
Practice Address - Phone:508-587-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0335380Medicaid
MAW16283OtherBCBS
MA0027835OtherNHP
81206Medicare UPIN
MAW17312Medicare ID - Type Unspecified