Provider Demographics
NPI:1851731459
Name:RIDDER, BRANDON (OD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:RIDDER
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 1:101 W DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NE
Mailing Address - Zip Code:68788-1407
Mailing Address - Country:US
Mailing Address - Phone:402-372-3266
Mailing Address - Fax:
Practice Address - Street 1:101 W DECATUR ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:NE
Practice Address - Zip Code:68788-1407
Practice Address - Country:US
Practice Address - Phone:402-372-3266
Practice Address - Fax:402-372-5736
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002602152W00000X
NE1396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE465019378OtherBLUE CROSS BLUE SHIELD OF NE
NE465019378Medicaid
NE465019378Medicaid
NE465019378OtherBLUE CROSS BLUE SHIELD OF NE