Provider Demographics
NPI:1730151572
Name:DENNIS M BRTVA
Entity type:Organization
Organization Name:DENNIS M BRTVA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRTVA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-663-2211
Mailing Address - Street 1:2109 N VETERANS PKWY
Mailing Address - Street 2:STE 2
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-0910
Mailing Address - Country:US
Mailing Address - Phone:309-663-2211
Mailing Address - Fax:309-664-2971
Practice Address - Street 1:2109 N VETERANS PKWY
Practice Address - Street 2:STE 2
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0910
Practice Address - Country:US
Practice Address - Phone:309-663-2211
Practice Address - Fax:309-664-2971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05721380OtherBLUE CROSS/BLUE SHIELD
IL991460Medicare ID - Type Unspecified