Provider Demographics
NPI:1871517805
Name:POOLE, BRIAN JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAMES
Last Name:POOLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 FLEETWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2019
Practice Address - Country:US
Practice Address - Phone:864-522-3970
Practice Address - Fax:864-522-3975
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1414152W00000X
GAOPT002306152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA14950281Medicare PIN
V10096Medicare UPIN