Provider Demographics
NPI:1760906135
Name:DISTERHEFT, BRITTANY RAE (OD)
Entity Type:Individual
Prefix:MRS
First Name:BRITTANY
Middle Name:RAE
Last Name:DISTERHEFT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2023 DORCHESTER LN UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-2640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13115 WICKER AVE STE E
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-7400
Practice Address - Country:US
Practice Address - Phone:219-374-7800
Practice Address - Fax:219-374-5196
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004052A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist