Provider Demographics
NPI:1346215811
Name:HASSEBROCK, MERVIN R (OD)
Entity Type:Individual
Prefix:DR
First Name:MERVIN
Middle Name:R
Last Name:HASSEBROCK
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 50
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-0050
Mailing Address - Country:US
Mailing Address - Phone:563-659-8141
Mailing Address - Fax:563-659-2121
Practice Address - Street 1:1107 9TH AVE
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-0050
Practice Address - Country:US
Practice Address - Phone:563-659-8141
Practice Address - Fax:563-659-2121
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1676152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0156042Medicaid
IA580000760OtherRAILROAD RETIREMENT
IA410036929OtherLOWDEN RAILROAD RETIREMNT
IA44821Medicare ID - Type UnspecifiedLOWDEN OFFICE LOCATION
IA0156042Medicaid
IA580000760OtherRAILROAD RETIREMENT
IA15604Medicare ID - Type Unspecified