Provider Demographics
NPI:1124197538
Name:BRADTKE, REBEKAH YVONNE
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:YVONNE
Last Name:BRADTKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 12TH AVE SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DYERSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52040-2416
Mailing Address - Country:US
Mailing Address - Phone:563-875-2344
Mailing Address - Fax:563-875-2344
Practice Address - Street 1:1213 12TH AVE SE
Practice Address - Street 2:SUITE 103
Practice Address - City:DYERSVILLE
Practice Address - State:IA
Practice Address - Zip Code:52040-2416
Practice Address - Country:US
Practice Address - Phone:563-875-2344
Practice Address - Fax:563-875-2344
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0449512Medicaid
IA5329280001Medicare ID - Type Unspecified