Healthcare Provider Details

I. General information

NPI: 1972207637
Provider Name (Legal Business Name): MR. BRANDON ALLAN TIPPIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 BETHEL RD
COLUMBUS OH
43220
US

IV. Provider business mailing address

2700 BETHEL RD
COLUMBUS OH
43220
US

V. Phone/Fax

Practice location:
  • Phone: 614-326-0761
  • Fax: 614-326-0798
Mailing address:
  • Phone: 614-326-0761
  • Fax: 614-326-0798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.017544-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: