Provider Demographics
NPI:1104877398
Name:AMMERAAL, BRET A (OD)
Entity type:Individual
Prefix:DR
First Name:BRET
Middle Name:A
Last Name:AMMERAAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 ZEIER RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-7415
Mailing Address - Country:US
Mailing Address - Phone:608-246-2161
Mailing Address - Fax:608-246-8573
Practice Address - Street 1:2201 ZEIER RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-7415
Practice Address - Country:US
Practice Address - Phone:608-246-2161
Practice Address - Fax:608-246-0136
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38450700Medicaid
WI38450700Medicaid
WI0154160106Medicare PIN