Provider Demographics
NPI:1760112973
Name:BRECHTELSBAUER, ANTHONY JACOB (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JACOB
Last Name:BRECHTELSBAUER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:919 ESSEX PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3884
Mailing Address - Country:US
Mailing Address - Phone:517-230-5547
Mailing Address - Fax:
Practice Address - Street 1:2825 HUNTERS TRL LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3429
Practice Address - Country:US
Practice Address - Phone:608-742-5522
Practice Address - Fax:608-745-3054
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI3903152W00000X
MI4901005627152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760112973Medicaid