Provider Demographics
NPI:1811984669
Name:BRAZIS, PETER T III (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:T
Last Name:BRAZIS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 N. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:630-668-8250
Mailing Address - Fax:630-668-8916
Practice Address - Street 1:2105 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-668-8250
Practice Address - Fax:630-668-8916
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-052950207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180012223OtherRR MEDICARE
IL036052950Medicaid
IL0534150001Medicare NSC
ILP01042Medicare PIN
IL180012223OtherRR MEDICARE
IL036052950Medicaid
IL0534150002Medicare NSC
IL0534150003Medicare NSC