MEDICARE: DR. JEREMY JAMES BRODERSEN 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	2181	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477664902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY JAMES BRODERSEN O.D.

Provider Business Mailing Address
First Line	:	3400 WALDEN AVE
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4618
Country	:	US
Telephone Number	:	712-276-2415
Fax Number	:

Provider Business Practice Location Address
First Line	:	3539 SOUTHERN HILLS DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4750
Country	:	US
Telephone Number	:	712-276-2323
Fax Number	:	712-274-9986

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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