Healthcare Provider Details

I. General information

NPI: 1508033622
Provider Name (Legal Business Name): DR. WILLIAM F. BRIGHAM, OPTOMETRIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 W WAYNE ST
FORT WAYNE IN
46802-3976
US

IV. Provider business mailing address

902 W WAYNE ST
FORT WAYNE IN
46802-3976
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-9421
  • Fax: 260-422-9422
Mailing address:
  • Phone: 260-422-9421
  • Fax: 260-422-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001470
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number18001470
License Number StateIN

VIII. Authorized Official

Name: DR. WILLIAM F. BRIGHAM
Title or Position: PRESIDENT
Credential: OD
Phone: 260-422-9421