MEDICARE: JON BRANTON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	841-290T	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	841-290T	OTHER	LA	STATE LIC#

General Provider Information

NPI Number	:	1275500696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON BRANTON O.D.

Provider Business Mailing Address
First Line	:	451 ASHLEY RIDGE BLVD
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7229
Country	:	US
Telephone Number	:	318-222-5555
Fax Number	:	318-222-6414

Provider Business Practice Location Address
First Line	:	451 ASHLEY RIDGE BLVD
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7229
Country	:	US
Telephone Number	:	318-222-5555
Fax Number	:	318-222-6414

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	07/08/2007

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Directions to “ JON BRANTON O.D.” Practice Location

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