Healthcare Provider Details

I. General information

NPI: 1710686118
Provider Name (Legal Business Name): BRANDON LA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 W PLANO PKWY
PLANO TX
75093-5613
US

IV. Provider business mailing address

250 AVENUE K SW STE 200
WINTER HAVEN FL
33880-3919
US

V. Phone/Fax

Practice location:
  • Phone: 469-999-2747
  • Fax: 469-606-0925
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number10779T
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10779T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: