MEDICARE: BRIAN K. SHANDLEY OD PA

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	5022TG	TX

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

General Provider Information

NPI Number	:	1326262858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIAN K. SHANDLEY OD PA

Provider Business Mailing Address
First Line	:	120 HIGHWAY 332 W
Second Line	:	SUITE A5
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-4017
Country	:	US
Telephone Number	:	979-297-3095
Fax Number	:	979-297-5410

Provider Business Practice Location Address
First Line	:	120 HIGHWAY 332 W
Second Line	:	SUITE A5
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-4017
Country	:	US
Telephone Number	:	979-297-3095
Fax Number	:	979-297-5410

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN SHANDLEY
Credential	:
Telephone Number	:	979-297-8188

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	02/19/2013

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