MEDICARE: BRETT REYNOLDS OD

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	OPC3269	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	410043221	OTHER		RR MEDICARE
2	410045559	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	20933	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1942346911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT REYNOLDS OD

Provider Business Mailing Address
First Line	:	3830 S HIGHWAY A1A STE 11
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-3152
Country	:	US
Telephone Number	:	321-308-2015
Fax Number	:	321-308-2017

Provider Business Practice Location Address
First Line	:	3830 S HIGHWAY A1A STE 11
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-3152
Country	:	US
Telephone Number	:	321-308-2015
Fax Number	:	321-308-2017

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	09/29/2008

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