Provider Demographics
NPI:1760559223
Name:BROEK, VERLYN DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:VERLYN
Middle Name:DEAN
Last Name:BROEK
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 1:215 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6139
Mailing Address - Country:US
Mailing Address - Phone:208-734-5100
Mailing Address - Fax:208-734-5134
Practice Address - Street 1:215 4TH AVE N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6139
Practice Address - Country:US
Practice Address - Phone:208-734-5100
Practice Address - Fax:208-734-5134
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015324OtherBLUE SHIELD
IDV5020OtherBLUE CROSS
ID1591370Medicare ID - Type UnspecifiedOPTOMETRIST