Provider Demographics
NPI:1164616900
Name:BRITZKE, DAVID ROGER (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROGER
Last Name:BRITZKE
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 1:830 PARKWAY AVE STE E
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9343
Mailing Address - Country:US
Mailing Address - Phone:574-970-7444
Mailing Address - Fax:
Practice Address - Street 1:830 PARKWAY AVE STE E
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9343
Practice Address - Country:US
Practice Address - Phone:574-970-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003206152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200393840AMedicaid
IN200393840AMedicaid