Provider Demographics
NPI:1679759229
Name:KYLE A. BRODIE, O.D., INC.
Entity Type:Organization
Organization Name:KYLE A. BRODIE, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-931-2020
Mailing Address - Street 1:107 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43469-1333
Mailing Address - Country:US
Mailing Address - Phone:419-849-3811
Mailing Address - Fax:567-482-4006
Practice Address - Street 1:107 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:OH
Practice Address - Zip Code:43469-1333
Practice Address - Country:US
Practice Address - Phone:419-849-3811
Practice Address - Fax:567-482-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2049232Medicaid
40207089Medicare PIN
0771588Medicare PIN
OH2049232Medicaid
OH5825270001Medicare NSC
OH9320352Medicare PIN
OH9320351Medicare PIN