Provider Demographics
NPI:1003995705
Name:MICHAEL PAUL BRODSKY
Entity Type:Organization
Organization Name:MICHAEL PAUL BRODSKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BRODSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:610-266-6666
Mailing Address - Street 1:265 LEHIGH VALLEY MALL
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:PA
Mailing Address - Zip Code:18052-5719
Mailing Address - Country:US
Mailing Address - Phone:610-266-6666
Mailing Address - Fax:610-266-2984
Practice Address - Street 1:265 LEHIGH VALLEY MALL
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-5719
Practice Address - Country:US
Practice Address - Phone:610-266-6666
Practice Address - Fax:610-266-2984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-000155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABR114049Medicare ID - Type Unspecified