Provider Demographics
NPI:1982711354
Name:BRODY, RUSSELL M (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:M
Last Name:BRODY
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 1:1544 SHERMER RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5347
Mailing Address - Country:US
Mailing Address - Phone:847-498-4770
Mailing Address - Fax:847-498-6909
Practice Address - Street 1:1544 SHERMER RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5347
Practice Address - Country:US
Practice Address - Phone:847-498-4770
Practice Address - Fax:847-498-6909
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK32646Medicare PIN
IL5799900001Medicare NSC
ILK32736Medicare PIN
ILU83343Medicare UPIN