Provider Demographics
NPI:1659392207
Name:BREIWA, JOHN NORBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NORBERT
Last Name:BREIWA
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 5000
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5000
Mailing Address - Country:US
Mailing Address - Phone:270-842-0383
Mailing Address - Fax:270-842-0485
Practice Address - Street 1:335 NEW TOWNE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7966
Practice Address - Country:US
Practice Address - Phone:270-842-0383
Practice Address - Fax:270-842-0485
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY833DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000052155OtherANTHEM
KYKY833OtherVISION BENEFITS AMERICA
KY77008332Medicaid
KY39417000OtherDAVIS VISION
KY1267730001OtherDMEOPS
KY611338655-0118OtherNVA
KYKY0833OtherEYEMED VISION
KYKY833OtherVISION BENEFITS AMERICA
KY77008332Medicaid
KY1267730001Medicare NSC