Healthcare Provider Details

I. General information

NPI: 1013227370
Provider Name (Legal Business Name): MEDRO JOSEPH BRODEUR III, O.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 S MAIN ST
GERALD MO
63037-2270
US

IV. Provider business mailing address

356 S MAIN ST BOX 81
GERALD MO
63037-2270
US

V. Phone/Fax

Practice location:
  • Phone: 573-764-2177
  • Fax:
Mailing address:
  • Phone: 573-764-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2435
License Number StateMO

VIII. Authorized Official

Name: DR. MEDRO JOSEPH BRODEUR III
Title or Position: OWNER
Credential: O.D
Phone: 573-764-2177