MEDICARE: DR. BRANDON WILLIAM CORNISH 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	OPC004217	FL

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	:	1396937470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRANDON WILLIAM CORNISH O.D.

Provider Business Mailing Address
First Line	:	640 N FEDERAL HWY
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-4686
Country	:	US
Telephone Number	:	954-522-3918
Fax Number	:	954-522-5137

Provider Business Practice Location Address
First Line	:	640 N FEDERAL HWY
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-4686
Country	:	US
Telephone Number	:	954-522-3918
Fax Number	:	954-522-5137

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

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	09/10/2015

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