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General NPI Number Information
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NPI Number | 1790978575
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Entity Type | Organization
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Legal Business Name | MEDRO JOSEPH BRODEUR III, O.D., P.C.
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Dates
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Enumeration Date | 08/24/2007
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Last Update Date | 02/21/2013
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Provider Practice Location Address
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Address Line | 531 E WASHINGTON AVE
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City | OWENSVILLE
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State | MO
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Zip | 65066-1410
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Country | US
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Telephone | 573-437-8004
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Fax | 573-437-8004
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Provider Business Mailing Address
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Address Line | 531 E WASHINGTON AVE
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City | OWENSVILLE
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State | MO
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Zip | 65066-1410
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Country | US
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Telephone | 573-437-8004
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Fax | 573-437-8004
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MEDRO JOSEPH BRODEUR III
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Credential | O.D.
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Telephone | 573-437-8004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | TO2435
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License Number State | MO
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