Provider Demographics
NPI:1821068487
Name:BRODEUR, MEDRO JOSEPH III (OD)
Entity Type:Individual
Prefix:DR
First Name:MEDRO
Middle Name:JOSEPH
Last Name:BRODEUR
Suffix:III
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 1:531 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066-1410
Mailing Address - Country:US
Mailing Address - Phone:573-437-8004
Mailing Address - Fax:573-437-8004
Practice Address - Street 1:531 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-1410
Practice Address - Country:US
Practice Address - Phone:573-437-8004
Practice Address - Fax:573-437-8004
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO311695118Medicaid
MO311695118Medicaid
MO000091274Medicare ID - Type Unspecified