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General NPI Number Information
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NPI Number | 1316166697
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Entity Type | Individual
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Provider Name | ICEM E BREWER O.D.
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Gender | Male
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 07/06/2011
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Provider Practice Location Address
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Address Line | 4201 N SHILOH DR STE 1235
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-5303
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Country | US
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Telephone | 479-444-8705
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Fax |
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Provider Business Mailing Address
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Address Line | 2391 N HIDDEN CREEK DR
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City | FAYETTEVILLE
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State | AR
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Zip | 72704-6353
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Country | US
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Telephone | 479-225-1857
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 2559
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License Number State | AR
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