Provider Demographics
NPI:1811993462
Name:DRAKE, STEVEN P (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:P
Last Name:DRAKE
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:PO BOX 620
Mailing Address - Street 2:
Mailing Address - City:GILLETT
Mailing Address - State:WI
Mailing Address - Zip Code:54124-0620
Mailing Address - Country:US
Mailing Address - Phone:920-855-2117
Mailing Address - Fax:920-855-2331
Practice Address - Street 1:130 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GILLETT
Practice Address - State:WI
Practice Address - Zip Code:54124-9386
Practice Address - Country:US
Practice Address - Phone:920-855-2117
Practice Address - Fax:920-855-2331
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38564000Medicaid
WI410002826Medicare PIN
WIT61803Medicare UPIN
WI0621480001Medicare NSC
WI38564000Medicaid