Provider Demographics
NPI:1194866004
Name:BRODOSKI, MICHAEL N
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:N
Last Name:BRODOSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37650 PROFESSIONAL CTR DR STE 125 A
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154
Mailing Address - Country:US
Mailing Address - Phone:734-953-0233
Mailing Address - Fax:734-462-1496
Practice Address - Street 1:37650 PROFESSIONAL CTR DR STE 125 A
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:734-953-0233
Practice Address - Fax:734-462-1496
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540220276OtherBCBS