Provider Demographics
NPI:1861108706
Name:PALL, BRIAN (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:PALL
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 1:3878 DYLAN CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-2707
Mailing Address - Country:US
Mailing Address - Phone:904-629-2289
Mailing Address - Fax:
Practice Address - Street 1:7500 CENTURION PKWY STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0517
Practice Address - Country:US
Practice Address - Phone:904-629-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3607152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist