Provider Demographics
NPI:1255426276
Name:SELLERS, BRIAN LEE (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
Last Name:SELLERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2196 EMPORIUM DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305
Mailing Address - Country:US
Mailing Address - Phone:731-664-8550
Mailing Address - Fax:731-664-8599
Practice Address - Street 1:2196 EMPORIUM DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-664-8550
Practice Address - Fax:731-664-8599
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0DT1821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U69621Medicare UPIN
TN3941760Medicare ID - Type Unspecified