Healthcare Provider Details

I. General information

NPI: 1316300163
Provider Name (Legal Business Name): BRANDON RAY LA FUENTE BCO, BADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 BANDIT PT
EDMOND OK
73025-2832
US

IV. Provider business mailing address

2104 BANDIT PT
EDMOND OK
73025-2832
US

V. Phone/Fax

Practice location:
  • Phone: 405-620-2543
  • Fax:
Mailing address:
  • Phone: 405-620-2543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: