Healthcare Provider Details

I. General information

NPI: 1255635348
Provider Name (Legal Business Name): ANNETTE BRABHAM OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N JOHN SIMS PKWY
VALPARAISO FL
32580-1005
US

IV. Provider business mailing address

111 N JOHN SIMS PKWY
VALPARAISO FL
32580-1005
US

V. Phone/Fax

Practice location:
  • Phone: 850-729-8711
  • Fax: 850-729-8713
Mailing address:
  • Phone: 850-729-8711
  • Fax: 850-729-8713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP0002698
License Number StateFL

VIII. Authorized Official

Name: DR. ANNETTE BRABHAM
Title or Position: OWNER/DOCTOR
Credential: O.D
Phone: 850-729-8711