Provider Demographics
NPI:1477664902
Name:BRODERSEN, JEREMY JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JAMES
Last Name:BRODERSEN
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 1:3400 WALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4618
Mailing Address - Country:US
Mailing Address - Phone:712-276-2415
Mailing Address - Fax:
Practice Address - Street 1:3539 SOUTHERN HILLS DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4750
Practice Address - Country:US
Practice Address - Phone:712-276-2323
Practice Address - Fax:712-274-9986
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1289819Medicaid
IA1289819Medicaid
I10264Medicare ID - Type Unspecified