Provider Demographics
NPI:1144482548
Name:BROTT, HEIDI GAIL (OD)
Entity type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:GAIL
Last Name:BROTT
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 1:4000 US HIGHWAY 93 S
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7347
Mailing Address - Country:US
Mailing Address - Phone:405-251-3679
Mailing Address - Fax:406-251-3715
Practice Address - Street 1:4000 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7347
Practice Address - Country:US
Practice Address - Phone:406-251-3679
Practice Address - Fax:406-251-3715
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0484120Medicaid
MT0484120Medicaid
MT000025094Medicare PIN