Healthcare Provider Details

I. General information

NPI: 1457422651
Provider Name (Legal Business Name): SHAWN A BRAND O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 N HARRISON ST STE 104
PRINCETON NJ
08540-3521
US

IV. Provider business mailing address

419 N HARRISON ST STE 104
PRINCETON NJ
08540-3521
US

V. Phone/Fax

Practice location:
  • Phone: 99-219-4376
  • Fax: 609-921-0277
Mailing address:
  • Phone: 609-921-9437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00604200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: