Provider Demographics
NPI:1730578212
Name:DANIEL J BROZA, O.D., PLLC
Entity type:Organization
Organization Name:DANIEL J BROZA, O.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROZA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-345-0975
Mailing Address - Street 1:5312 FOUNDATION ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2867
Mailing Address - Country:US
Mailing Address - Phone:757-345-0975
Mailing Address - Fax:757-746-2046
Practice Address - Street 1:12121 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6916
Practice Address - Country:US
Practice Address - Phone:757-746-2014
Practice Address - Fax:757-746-2046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000779261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00X764T01OtherMEDICARE PTAN
VA00X764T01OtherMEDICARE PTAN