Provider Demographics
NPI:1083924740
Name:BRASEL, MICAH (OD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:BRASEL
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 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:300 W RANDOLPH
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471
Practice Address - Country:US
Practice Address - Phone:618-283-7100
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010422152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist