Provider Demographics
NPI:1134291487
Name:BREKKE, JAMES (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BREKKE
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 1:361 TROUT BROOK TRL
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-6729
Mailing Address - Country:US
Mailing Address - Phone:715-808-1159
Mailing Address - Fax:
Practice Address - Street 1:7150 VALLEY CREEK PLZ
Practice Address - Street 2:SUITE 216
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2271
Practice Address - Country:US
Practice Address - Phone:651-738-4886
Practice Address - Fax:651-738-3744
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2233152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN335217000Medicaid
MN410002437Medicare PIN
MN410002073Medicare PIN
MN410002079Medicare PIN
MN410002080Medicare PIN
MN410001879Medicare PIN
MN410000371Medicare PIN
MN410001881Medicare PIN
MN410002076Medicare PIN
U25326Medicare UPIN
MN410002072Medicare PIN
MN410001880Medicare PIN
MN410002568Medicare PIN
MN410002075Medicare PIN
MN410002077Medicare PIN
MN410002078Medicare PIN