Provider Demographics
NPI:1013993393
Name:MECKELBERG, BRIAN L (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:MECKELBERG
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:PO BOX 366
Mailing Address - Street 2:N2577 PLAZA RD
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0366
Mailing Address - Country:US
Mailing Address - Phone:920-787-3837
Mailing Address - Fax:920-787-1613
Practice Address - Street 1:N2577 PLAZA RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-7706
Practice Address - Country:US
Practice Address - Phone:920-787-3837
Practice Address - Fax:920-787-1613
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38525000Medicaid
T62740Medicare UPIN
WI38525000Medicaid