Provider Demographics
NPI:1194754879
Name:BRAKE-NORDER, JEANNINE M (OD)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:M
Last Name:BRAKE-NORDER
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 1:123 LANSING STREET
Mailing Address - Street 2:EYE CARE ASSOCIATES OF CHARLOTTE PLLC
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813
Mailing Address - Country:US
Mailing Address - Phone:517-543-2020
Mailing Address - Fax:517-543-0311
Practice Address - Street 1:123 LANSING STREET
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813
Practice Address - Country:US
Practice Address - Phone:517-543-2020
Practice Address - Fax:517-543-0311
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003751152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJB003751OtherBCBS OF MI
MI2200102OtherPHP OF MID MICHIGAN
410029431OtherRAILROAD MEDICARE
MIJB003751OtherBCBS OF MI
1039600001Medicare NSC
OM15140001Medicare ID - Type Unspecified