Provider Demographics
NPI:1710686118
Name:LA, BRANDON (OD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:LA
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 1:250 AVENUE K SW STE 200
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 AVENUE K SW STE 200
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3919
Practice Address - Country:US
Practice Address - Phone:210-283-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6363152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152W00000XEye and Vision Services ProvidersOptometrist