Provider Demographics
NPI:1235226671
Name:BREWER, GRETCHEN (OD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:BREWER
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2329 COTTMAN AVE
Mailing Address - Street 2:ROOSEVELT MALL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149
Mailing Address - Country:US
Mailing Address - Phone:215-332-7228
Mailing Address - Fax:215-332-9337
Practice Address - Street 1:2329 COTTMAN AVE
Practice Address - Street 2:ROSSEVELT MALL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149
Practice Address - Country:US
Practice Address - Phone:215-332-7228
Practice Address - Fax:215-332-9337
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PW2037984000OtherKEYSTONE HEALTHPLAN EAST
PABR1345378OtherBCBS PA BLUE SHIELD
PA01975373Medicaid
PA1345378OtherPERSONAL CHOICE BLUE CHOI
PA7377317OtherAETNA
PA1345378OtherPERSONAL CHOICE BLUE CHOI
PW2037984000OtherKEYSTONE HEALTHPLAN EAST