Provider Demographics
NPI:1578755856
Name:MILDENBERGER, BRETT GORDON (OD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:GORDON
Last Name:MILDENBERGER
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 1707
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-1707
Mailing Address - Country:US
Mailing Address - Phone:406-363-2873
Mailing Address - Fax:
Practice Address - Street 1:473 CAYUSE TRL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:MT
Practice Address - Zip Code:59828-9259
Practice Address - Country:US
Practice Address - Phone:406-363-2873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT 521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist