Basic Information
| Provider Information | |||||||||
| NPI: | 1083651988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LALLATHIN | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 N 22ND ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025987488 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 COMMON DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799365922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152672020 | ||||||||
| FaxNumber: | 9155954460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5069TG | TX | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 2133 | OK | N | Eye and Vision Services Providers | Optometrist |
No ID Information.