MEDICARE: DR. BRAD HAROLD EWALD O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1347-035	WI

General Provider Information

NPI Number	:	1396863387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRAD HAROLD EWALD O.D.

Provider Business Mailing Address
First Line	:	2900 S MAIN ST
Second Line	:
City	:	RICE LAKE
State	:	WI
Zip	:	54868
Country	:	US
Telephone Number	:	715-234-1511
Fax Number	:	715-434-1513

Provider Business Practice Location Address
First Line	:	2900 S MAIN ST
Second Line	:
City	:	RICE LAKE
State	:	WI
Zip	:	54868
Country	:	US
Telephone Number	:	715-234-1511
Fax Number	:	715-434-1513

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	12/09/2008

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