MEDICARE: BRENDA DEFORREST 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	261Q00000X	Clinic/Center	FL2617	FL

General Provider Information

NPI Number	:	1477733780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENDA DEFORREST OD PA

Provider Business Mailing Address
First Line	:	5006 DR PHILLIPS BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-3310
Country	:	US
Telephone Number	:	407-289-8819
Fax Number	:	407-296-7121

Provider Business Practice Location Address
First Line	:	5006 DR PHILLIPS BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-3310
Country	:	US
Telephone Number	:	407-289-8819
Fax Number	:	407-296-7121

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRENDA DEFORREST
Credential	:	OD
Telephone Number	:	407-298-8819

Provider Enumeration Date	:	11/05/2007
Last Update Date	:	08/04/2025

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