Provider Demographics
NPI:1356367866
Name:WIENER, BROOKE A (OD)
Entity type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:A
Last Name:WIENER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57812 FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-9068
Mailing Address - Country:US
Mailing Address - Phone:320-469-4349
Mailing Address - Fax:
Practice Address - Street 1:203 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037-8100
Practice Address - Country:US
Practice Address - Phone:320-384-0123
Practice Address - Fax:320-384-0123
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3159152W00000X
IA02368152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0735753Medicaid
MN1356367866Medicaid
IA0735753Medicaid