Provider Demographics
NPI:1235190109
Name:YACKELS, TODD M (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:M
Last Name:YACKELS
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 1:1221 COBBLESTONE PL
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4585
Mailing Address - Country:US
Mailing Address - Phone:262-335-2902
Mailing Address - Fax:
Practice Address - Street 1:2950 S CHASE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-6407
Practice Address - Country:US
Practice Address - Phone:414-483-1092
Practice Address - Fax:414-483-1095
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2479-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38582700Medicaid
WI38582700Medicaid