MEDICARE: BRANDON CALLOW 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	18003992A	IN

General Provider Information

NPI Number	:	1639522642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON CALLOW O.D.

Provider Business Mailing Address
First Line	:	9610 LIMA ROAD SUITE 103
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818
Country	:	US
Telephone Number	:	260-440-8388
Fax Number	:	260-999-5645

Provider Business Practice Location Address
First Line	:	9610 LIMA ROAD
Second Line	:	SUITE 103
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-9998
Country	:	US
Telephone Number	:	260-440-8388
Fax Number	:	260-999-5645

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

Provider Enumeration Date	:	07/14/2016
Last Update Date	:	03/11/2024

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