Provider Demographics
NPI:1831228600
Name:NIEBRUGGE, PATRICK M (OPTOMETRIST OD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:M
Last Name:NIEBRUGGE
Suffix:
Gender:M
Credentials:OPTOMETRIST 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 528
Mailing Address - Street 2:
Mailing Address - City:CASEY
Mailing Address - State:IL
Mailing Address - Zip Code:62420-0528
Mailing Address - Country:US
Mailing Address - Phone:217-932-2310
Mailing Address - Fax:217-932-4674
Practice Address - Street 1:1279 E US HWY 40
Practice Address - Street 2:
Practice Address - City:CASEY
Practice Address - State:IL
Practice Address - Zip Code:62420-0528
Practice Address - Country:US
Practice Address - Phone:217-932-2310
Practice Address - Fax:217-932-4674
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0706010001OtherMEDICARE JURISDICTION B D
T37818Medicare UPIN
IN0706010001OtherMEDICARE JURISDICTION B D