Provider Demographics
NPI:1457894404
Name:BRAKEFIELD, CHARLES TIMOTHY (OCULARIST)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:TIMOTHY
Last Name:BRAKEFIELD
Suffix:
Gender:M
Credentials:OCULARIST
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:BRAKEFIELD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OCULARIST
Mailing Address - Street 1:2725 MARSHALL CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2288
Mailing Address - Country:US
Mailing Address - Phone:608-661-9030
Mailing Address - Fax:
Practice Address - Street 1:6401 ODANA RD STE 23
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1126
Practice Address - Country:US
Practice Address - Phone:608-661-9030
Practice Address - Fax:608-661-9040
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI036-0002195093-04156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41744100Medicaid
WI0829340001OtherMEDICARE PTAN