Provider Demographics
NPI:1922053040
Name:BROECKER, STACEY T (OD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:T
Last Name:BROECKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2356 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1897
Mailing Address - Country:US
Mailing Address - Phone:651-645-8124
Mailing Address - Fax:651-645-8125
Practice Address - Street 1:2356 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1897
Practice Address - Country:US
Practice Address - Phone:651-645-8124
Practice Address - Fax:651-645-8125
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN808023200Medicaid