Basic Information
Provider Information | |||||||||
NPI: | 1033292982 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHINNEY | ||||||||
FirstName: | BRENT | ||||||||
MiddleName: | ROY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 515 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | CO | ||||||||
PostalCode: | 805505131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704600154 | ||||||||
FaxNumber: | 9704603032 | ||||||||
Practice Location | |||||||||
Address1: | 515 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | CO | ||||||||
PostalCode: | 805505131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704600154 | ||||||||
FaxNumber: | 9704603032 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 01/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3995TX | WA | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 2598 | CO | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 5856769 | 01 | WA | AETNA | OTHER | 911035418-BU1061 | 01 | WA | REGENCE | OTHER | 2031227 | 05 | WA |   | MEDICAID | 22095 | 01 | WA | L&I PROVIDER # | OTHER | 5493150001 | 01 | WA | DMERC | OTHER |