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General NPI Number Information
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NPI Number | 1245301746
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Entity Type | Individual
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Provider Name | BRENTON DOUGLAS ORMISTON O.D.
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Gender | Male
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 3275 W 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-4835
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Country | US
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Telephone | 812-287-8742
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Fax | 812-287-8752
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Provider Business Mailing Address
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Address Line | 2808 E WINSTON ST
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City | BLOOMINGTON
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State | IN
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Zip | 47401-4450
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Country | US
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Telephone | 812-361-5864
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT-2544
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18003561A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1833DT
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License Number State | KY
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Taxonomy #4
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1595-628T
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License Number State | LA
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Taxonomy #5
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 5992
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License Number State | OH
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Taxonomy #6
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 8142T
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License Number State | TX
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