Provider Demographics
NPI:1801933627
Name:BROSE, WILLIAM CLIFFORD (OD,)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CLIFFORD
Last Name:BROSE
Suffix:
Gender:M
Credentials:OD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6632 FLAG AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55428-1853
Mailing Address - Country:US
Mailing Address - Phone:763-535-7011
Mailing Address - Fax:
Practice Address - Street 1:12131 ELM CREEK BLVD N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7093
Practice Address - Country:US
Practice Address - Phone:763-416-1983
Practice Address - Fax:763-416-4084
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN1544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1808007OtherDEFINITY HEALTH
MN2202190OtherMEDICA
MN168L0BROtherBLUE CROSS BLUE SHIELD
MNBR952237OtherHIGHMARK BLUE CROSS
MN219101033314OtherPREFERED ONE
MN121823900Medicaid
MNHP39712OtherHEALTH PARTNERS
MN2202190OtherMEDICA