Basic Information
| Provider Information | |||||||||
| NPI: | 1114914017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANLON | ||||||||
| FirstName: | BRADY | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1607 SAINT JAMES CT | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508780191 | ||||||||
| FaxNumber: | 8508788900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1607 SAINT JAMES CT | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508780191 | ||||||||
| FaxNumber: | 8508788900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003296A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 003 | 01 | IN | DAVIS VISION | OTHER | 200517920 | 05 | IN | MEDICAID | 200517920 | 01 | IN | CORESOURCE | OTHER | 000000368674 | 01 | IN | ANTHEM BCBS | OTHER | 200517920 | 01 | IN | HARMONY HEALTH | OTHER | 0356760001 | 01 | IN | DMERC | OTHER | 200517920 | 01 | IN | MANAGED HEALTH SERVICES | OTHER | 200517920 | 01 | IN | MOLINA | OTHER |