Provider Demographics
NPI:1598889289
Name:BRODSKY & WEIKUM, INC
Entity Type:Organization
Organization Name:BRODSKY & WEIKUM, INC
Other - Org Name:DR. ROGER WEIKUM
Other - Org Type:Other Name
Authorized Official - Title/Position:THERAPEUTIC OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WEIKUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:214-220-2425
Mailing Address - Street 1:2100 ROSS AVE # 260LB4
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-2739
Mailing Address - Country:US
Mailing Address - Phone:214-220-2425
Mailing Address - Fax:214-220-2488
Practice Address - Street 1:2100 ROSS AVE # 260LB4
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-2739
Practice Address - Country:US
Practice Address - Phone:214-220-2425
Practice Address - Fax:214-220-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002243TG152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT16351Medicare UPIN
TXTXB118985Medicare PIN