Provider Demographics
NPI:1700115409
Name:SCHWANTKE, BRAD ELLIOT (OD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:ELLIOT
Last Name:SCHWANTKE
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 1:4720 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3336
Mailing Address - Country:US
Mailing Address - Phone:651-426-2747
Mailing Address - Fax:
Practice Address - Street 1:4720 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3336
Practice Address - Country:US
Practice Address - Phone:651-426-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN3252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program