Provider Demographics
NPI:1730108283
Name:PRATTE, BRUCE WELTON (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WELTON
Last Name:PRATTE
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 1:1674 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2652
Mailing Address - Country:US
Mailing Address - Phone:937-322-6411
Mailing Address - Fax:937-399-2346
Practice Address - Street 1:1674 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2652
Practice Address - Country:US
Practice Address - Phone:937-322-6411
Practice Address - Fax:937-399-2346
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2836/T601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000005257OtherANTHEM BLUE CROSS BLUE SH
OH2220168OtherUNITED HEALTH CARE
OH0134367Medicaid
OH2220168OtherUNITED HEALTH CARE
OH0416554Medicare PIN
OH0302990001Medicare NSC