Provider Demographics
NPI:1982779898
Name:VETTER, BROOKE LOUISE (OD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:LOUISE
Last Name:VETTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 MCCULLOCH BLVD N STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5749
Mailing Address - Country:US
Mailing Address - Phone:928-855-5026
Mailing Address - Fax:
Practice Address - Street 1:1990 MCCULLOCH BLVD N STE 101
Practice Address - Street 2:LAKE HAVASU FAMILY EYECARE
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5749
Practice Address - Country:US
Practice Address - Phone:928-855-5026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5394153-9934152W00000X
AZ1566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5398210001Medicare NSC