Healthcare Provider Details

I. General information

NPI: 1407890262
Provider Name (Legal Business Name): BRUCE L BRODMERKLE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 WASHINGTON ST
CHILLICOTHEE MO
64601-1306
US

IV. Provider business mailing address

1115 WASHINGTON ST
CHILLICOTHEE MO
64601-1306
US

V. Phone/Fax

Practice location:
  • Phone: 660-646-3937
  • Fax: 660-646-4092
Mailing address:
  • Phone: 660-646-3937
  • Fax: 660-646-4092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02410
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: