Provider Demographics
NPI:1346396173
Name:BRAKKE, ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BRAKKE
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:5821 SPRAGUE COURT
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409
Practice Address - Country:US
Practice Address - Phone:253-456-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001774Medicaid
WAGAB20084Medicare PIN
WAG001050882Medicare PIN
WA2001774Medicaid
WAGAB20082Medicare PIN
WAT01977Medicare UPIN
WAGAB20083Medicare PIN
WAG8872250Medicare PIN