Provider Demographics
NPI:1083392088
Name:SOSALLA, BROOKE (OD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SOSALLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17569 PINE LN APT 1201
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-6522
Mailing Address - Country:US
Mailing Address - Phone:608-397-0053
Mailing Address - Fax:
Practice Address - Street 1:11960 LIONESS WAY STE 190
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-5640
Practice Address - Country:US
Practice Address - Phone:303-794-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist