Provider Demographics
NPI:1215955505
Name:BRANDSTATTER, EMILY BROOKE (OD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:BROOKE
Last Name:BRANDSTATTER
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-9244
Practice Address - Street 1:2500 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947
Practice Address - Country:US
Practice Address - Phone:574-722-5252
Practice Address - Fax:574-722-3202
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003423A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200857700Medicaid
INM400049369Medicare PIN
IN452570030Medicare PIN
IN151130CMedicare PIN
IN200857700Medicaid