1679759229 NPI number — KYLE A. BRODIE, O.D., INC.

Table of content: MAEGAN GORDON (NPI 1912425661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679759229 NPI number — KYLE A. BRODIE, O.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KYLE A. BRODIE, O.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679759229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 S WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43469-1333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-849-3811
Provider Business Mailing Address Fax Number:
567-482-4006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 S WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43469-1333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-849-3811
Provider Business Practice Location Address Fax Number:
567-482-4006
Provider Enumeration Date:
01/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRODIE
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
419-931-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2049232 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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