Provider Demographics
NPI:1134115009
Name:BRODSKY, MICHAEL PAUL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:BRODSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4693 BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049-1225
Mailing Address - Country:US
Mailing Address - Phone:610-965-5564
Mailing Address - Fax:610-965-3910
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2007-07-26
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
PAOEG000155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABR114049Medicare ID - Type Unspecified