Provider Demographics
NPI:1548307465
Name:BADER, BROOKE ANN (OD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANN
Last Name:BADER
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 1:126 BRIAR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1621
Mailing Address - Country:US
Mailing Address - Phone:440-453-6515
Mailing Address - Fax:
Practice Address - Street 1:4900 MIDWAY MALL
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2470
Practice Address - Country:US
Practice Address - Phone:440-324-1617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5538152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist