Healthcare Provider Details

I. General information

NPI: 1154325819
Provider Name (Legal Business Name): BRENT B FRY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 KINGSTON PIKE
KNOXVILLE TN
37934-2807
US

IV. Provider business mailing address

11111 KINGSTON PIKE
KNOXVILLE TN
37934-2807
US

V. Phone/Fax

Practice location:
  • Phone: 865-966-0100
  • Fax: 865-966-0007
Mailing address:
  • Phone: 865-966-0100
  • Fax: 865-966-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1904
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1904
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number1904
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTNOD1904
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: