Provider Demographics
NPI:1760557698
Name:DUNLAP, BRENT PATRICK (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:PATRICK
Last Name:DUNLAP
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 1:42 BRIARCLIFF PROFESSIONAL CENTER
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-932-1116
Mailing Address - Fax:815-932-9919
Practice Address - Street 1:42 BRIARCLIFF PROFESSIONAL CENTER
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-932-1116
Practice Address - Fax:815-932-9919
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL469363152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212386Medicare PIN
ILU86882Medicare UPIN
ILK21567Medicare PIN
IL5092680001Medicare NSC