Provider Demographics
NPI:1831262641
Name:BROG, LUKE DEWEY (OD)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:DEWEY
Last Name:BROG
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 800
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-0800
Mailing Address - Country:US
Mailing Address - Phone:307-883-4678
Mailing Address - Fax:
Practice Address - Street 1:122 PETERSEN PARKWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY296T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313773OtherBLUE CROSS BLUE SHIELD
WY285174OtherALTIUS HEALTH PLANS
WY5646844OtherCBSA
WY313773OtherBLUE CROSS BLUE SHIELD
WY285174OtherALTIUS HEALTH PLANS
WY20533Medicare ID - Type Unspecified