Provider Demographics
NPI:1508873571
Name:BRUBAKER, NADINE ISABELLE (OD)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:ISABELLE
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 E HERNDON AVENUE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720
Mailing Address - Country:US
Mailing Address - Phone:559-486-5000
Mailing Address - Fax:559-439-7854
Practice Address - Street 1:1360 E HERNDON AVENUE
Practice Address - Street 2:SUITE 301
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-486-5000
Practice Address - Fax:559-439-7854
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7425T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0074250Medicare ID - Type Unspecified
U79542Medicare UPIN