Provider Demographics
NPI:1306854062
Name:BROOKE, MICHAEL STEVEN (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEVEN
Last Name:BROOKE
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:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-0388
Mailing Address - Country:US
Mailing Address - Phone:605-256-6911
Mailing Address - Fax:605-256-9017
Practice Address - Street 1:302 N HARTH AVENUE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042
Practice Address - Country:US
Practice Address - Phone:605-256-6911
Practice Address - Fax:605-256-9017
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT507152W00000X
WA1533TX152W00000X
OR1626152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9202922Medicaid
SD9202922Medicaid
T02147Medicare UPIN