Provider Demographics
NPI:1811997802
Name:BRODKEY, DANIEL LOUIS (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LOUIS
Last Name:BRODKEY
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 1:5404 MORNINGSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-3136
Mailing Address - Country:US
Mailing Address - Phone:712-274-2020
Mailing Address - Fax:712-274-7095
Practice Address - Street 1:5404 MORNINGSIDE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-3136
Practice Address - Country:US
Practice Address - Phone:712-274-2020
Practice Address - Fax:712-274-7095
Is Sole Proprietor?:No
Enumeration Date:2005-07-31
Last Update Date:2007-12-03
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IA1635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0146670Medicaid
IAT00887Medicare UPIN
IA14667Medicare PIN
IA0146670Medicaid