Provider Demographics
NPI:1598752289
Name:BREHM, MICHAEL PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PAUL
Last Name:BREHM
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 1:17 MORNINGSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110
Mailing Address - Country:US
Mailing Address - Phone:518-428-9056
Mailing Address - Fax:
Practice Address - Street 1:760 HOOSICK RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-6697
Practice Address - Country:US
Practice Address - Phone:518-279-0641
Practice Address - Fax:518-279-0651
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV-006269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU82269Medicare UPIN