=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811653942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANNON HALIM OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2021
-----------------------------------------------------
Last Update Date | 01/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 173 PLAZA DR STE 1009
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94591-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-917-4053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 VICTORIA PARK
-----------------------------------------------------
City | HERCULES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94547-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-551-5069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 35070
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------