Provider Demographics
NPI:1407890262
Name:BRODMERKLE, BRUCE L (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:BRODMERKLE
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 1:1115 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-1306
Mailing Address - Country:US
Mailing Address - Phone:660-646-3937
Mailing Address - Fax:660-646-4092
Practice Address - Street 1:1115 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-1306
Practice Address - Country:US
Practice Address - Phone:660-646-3937
Practice Address - Fax:660-646-4092
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02410152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO311757003Medicaid
MOP00147426Medicare PIN
MO311757003Medicaid
MO258251686Medicare PIN
MOP00252064Medicare PIN
MOU12037Medicare UPIN
MOL531974Medicare PIN
MO4637030002Medicare NSC
MO4637030003Medicare NSC
MO4637030001Medicare NSC